1

Statements
Remember the problem, purpose and hypotheses statements that we worked so hard on last
semester? We will be using them again! They should be stated in your paper (just as we worked
on in your research proposal) but we are also asking you to spell them out here as a reminder of
the foundational basis for your research.

Purpose Statement:
The purpose of this research is to determine the impact of using a density override of the
contrast-enhanced spaceOAR on dose accuracy to the bladder, rectum, and PTV.
Problem Statement:
Enhancement of the contrast on the treatment planning CT scan is depicting artificially high HU
values that could impact dosimetric accuracy during treatment planning.
Hypotheses:
H1: The first research hypothesis (H1) is that using a density override for the contrast-enhanced
spaceOAR will decrease the percent mean dose by ≤ 5% to the bladder.
H10: The first null hypothesis (H10) is that using a density override for the contrast-enhanced
spaceOAR will increase the percent mean dose by ≥ 5% to the bladder.
H2: The second research hypothesis (H2) is that using a density override for the contrast-
enhanced spaceOAR will decrease the percent mean dose by ≤ 5% to the rectum.
H20: The second null hypothesis (H20) is that using a density override for the contrast-enhanced
spaceOAR will increase the percent mean dose by ≥ 5% to the rectum.
H3: The third research hypothesis (H3) is that using a density override for the contrast-enhanced
spaceOAR will decrease the percent mean dose by ≤ 5% to the PTV.
H30: The third null hypothesis (H30) is that using a density override for the contrast-enhanced
spaceOAR will increase the percent mean dose by ≥ 5% to the PTV.
 2

Change Matrix
A change matrix is required with every milestone document submission.
A detailed change matrix simplifies the review process and indicates to the instructors and
advisors that the author has demonstrated a clear and thorough response to reviewer comments.
Reviewer comments are not intended as an exhaustive list. It is the Learner’s responsibility to
correct any additional errors that are not specifically noted by the reviewer and to address the
requirements of the capstone project. All instances where changes have been made should be
clearly noted.
If, after discussion with the group, there are questions about a reviewer’s comments, it is the
responsibility of the group leader to reach out to the instructors and advisor via email for
clarification.
If, after discussion with the instructors, the author chooses not to make a requested change,
the author must provide a brief rationale, and describe how they addressed reviewer concerns.
Failures to consider, address, and notate within the Change Matrix will result in the manuscript
being returned to the group without comment.
Copy and paste the instructor’s comment from your draft into the matrix.
You will continuously build on this change matrix so that any/all comments can be reviewed at
any given time in the projects progress.
Title of Capstone: A dosimetric evaluation to determine the impact of using a density override
for the contrast-enhanced spaceOAR for prostate cancer

Group 1: Asila Lashkeri and Reta Zeto

Reviewer’s recommendation How addressed Page numbers

where change
appears
Matt Tobbler: Organized the paragraph with talking 12
This whole paragraph needs some about rectal toxicity, then introduced
better organization. You start with spaceOAR with advantages with
SpaceOAR, then jump to rectal side reduced dose to bladder and penile
effects, then back to space OAR, then bulb.
start talking about dose reduction to
the bladder and penile bulb. Wouldn't
it be better to start with talk about
rectal toxicity, then introduce
spaceOAR and it's advantage in
separating (not delineating) the rectum
from the PTV, then, if true, also
mention that there may also be
reduced dose to bladder and penile
bulb as a result of use of spaceOAR?

Nishele Lenards: Added some content  12

I agree. And this introduction is much
too short as it is so once you organize
 3

the flow better, you'll add content and

that will help.

Nishele Lenards: Revised the intro sentence  12

It seems like most of this paragraph is
about benefits of using contrast-
enhanced spaceOAR, so I think your
introductory sentence should introduce
the reader to that subject. You don't
need to remove anything here, just
start out with a better intro sentence.

Nishele Lenards: Revised with scholarly language  12

Scholarly language needs used. ....
how spacers are viewed on a CT
scan....

Nishele Lenards: Revised as suggested  12

For patients ineligible for a MRI
procedure due to reasons such as lack
of insurance coverage or having a
pacemaker, are ideal candidates for a
CT scan with the contrast-enhanced
spaceOAR.Fixed the doi the best we
could
Matt Tobbler Changed the wording of “fall off”  12
"fall off"?
Nishele Lenards: Revised the sentence  12
And, this sentence doesn't mesh well
with the one that follows. Just be more
clear about what you are trying to say
here.
Nishele Lenards:  Revised the words 12
'has been found to have' - wordy. 
Just say 'has' 

Matt Tobbler:  Revised the entire paragraph with 12

This is unclear to me here.  An HU added content 
value of 300 would be assumed to be
different than water.  I understand
what you are saying about KV vs MV
interactions, but if you don't trust the
HU value, why not and what
information do you have that suggests
that the override value should be
 4

different? 

Nishele Lenards:  Fixed the doi to fit.  Some of them 14

something is wrong with formatting don’t fit because they are too long. 
here as there is plenty of space to fit
the doi but it keeps going to the next
line. Your version had 533 page
number down on the next line as well
(but I moved it) so I think there is
something wrong with your
formatting. 

Nishele Lenards:  Rearranged the sentence to add the 13

IGRT techniques have assisted changes
clinicians to identify...

Nishele Lenards:  Created a new paragraph describing 13

Comment about introduction being too spaceOAR
short...

Nishele Lenards & Matt Tobler:  rearranged the paragraph as requested 13

Start the paragraph with side effects:
“In the past spaceOAR....”

Matt Tobler:  Modified the sentence to state 14

Are you talking about traditional or contrast-enhanced spaceOAR
contrast-enhanced spaceOAR
Matt Tobler & Nishelle Lenards  Modified the paragraph 14
Paragraph regarding fiducials

Matt Tobler:  Cited manufacturer specifications 14

What is the true density of contrast...

Nishelle Lenards:  Added the paragraph as requested 15

need to add the problem statement,
purpose and hypothesis before
materials and methods

Nishelle Lenards:  Removed spaces throughout the 15

Remove extra spaces document

Nishelle Lenards:  Treatment planning paragraph 15

Treatment planning section needs modified with more information
more data
5
6

AMA Referencing Quick Guide Checklist

Correctly using AMA formatting is one of the few aspects in the Capstone project that you have
complete control of whether it is your first outline submission or the final draft. Use this AMA
quick guide checklist to avoid common AMA formatting mistakes and receive the greatest
number of points possible. Not everyone has the ability to be an exceptional scholarly writer and
researcher, however, everyone has the capability of using AMA formatting correctly. Review
this guide for EVERY submission (discussion post, outline, draft) in the research courses and ask
yourself the following questions:

Task Submis Submissi Submissio Submissi Submissi Submissi Submiss

sion on Date: n Date: on Date: on Date: on Date: ion
Date: 8/3/22 Date:
6/25/22 7/13/22
Manuscript
Written in
past tense? ☒ ☒ ☒ ☐ ☐ ☐ ☐

Written in
size 12, ☒ ☒ ☒ ☐ ☐ ☐ ☐
Times New
Roman font
Paragraphs
include at ☒ ☒ ☒ ☐ ☐ ☐ ☐
least 3
sentences
Page
numbers?

**The default
font for page
numbers is
Calibri, size ☒ ☒ ☒ ☐ ☐ ☐ ☐
11 even after
you have
changed the
font in your
paper so
make sure to
check
Spell out ☒ ☒ ☒ ☐ ☐ ☐ ☐
abbreviation
at first use if
not
recognized
by AMA
7

***Remembe
r that you
may
add/subtract
content with
each draft so
something
that once
spelled out
might be
removed and
need to
spelled out
again
Spell out
numbers and
abbreviations
that begin a
sentence?

**If an
abbreviation ☐
must be ☒ ☒ ☒ ☐ ☐ ☐
spelled out to
begin a
sentence, do
not include the
abbreviation in
parentheses
after words
unless this is
the first use.
Numeric
values when
referring to
☒ ☒ ☒ ☐ ☐ ☐ ☐
numbers in
sentence
(“3”, not
“three”)
Reference
superscripts
after each ☒ ☒ ☒ ☐ ☐ ☐ ☐
sentence I
used a
reference?
OAR is ☒ ☒ ☒ ☐ ☐ ☐ ☐
properly
8

defined as
organS at risk.

**This is a
common
mistake, even
in journal
publications.
By saying
OARs, you
are implying
organs at
risks which
doesn’t make
sense
If I directly
cited an
author, did I
immediately
include the ☐ ☐ ☐ ☐ ☐ ☐ ☐
reference
superscript
following the
author’s
name?
Tables and
figures are
referenced in-
☐ ☐ ☒ ☐ ☐ ☐ ☐
text directly
following the
sentence (….
(Figure 1).
All terms ☒ ☒ ☒ ☐ ☐ ☐ ☐
must be
spelled out in
the abstract
and
manuscript at
first use

**So if you
refer to and
spell out
VMAT in the
abstract, you
must also
define the
9

term again in
the
manuscript
Scholarly
writing is
appropriate

**Do not use

terms such as
max, cord,
☒ ☒ ☒ ☐ ☐ ☐ ☐
rad onc,
simmed etc.
Spell out
these terms
and avoid
slang
All reference
of our
profession
should be
written as
“medical
dosimetrist” ☒ ☒ ☒ ☐ ☐ ☐ ☐
not just
“dosimetrist.”

**Remember
that there are
other types of
dosimetrists
Is my paper
formatted
according the
instructions? ☒ ☒ ☒ ☐ ☐
☐ ☐
Case study
vs. Research
Paper
Reference Page
Page break
before this ☒ ☒ ☒ ☐ ☐ ☐ ☐
section?
Capitalize ☒ ☒ ☒ ☐ ☐ ☐ ☐
the first
letter of the
first word
in the title
10

only
Abbreviate
and
☒ ☒ ☒ ☐ ☐ ☐ ☐
italicize the
journal?
Year,
volume,
issue and
page
number
written
without any
spaces?

**If you
didn’t find
one listed,
consider ☒ ☒ ☒ ☐ ☐ ☐ ☐
completing
another
literature
search
review. If
you cannot
find one,
reach out
to
instructor
for help
Doi?

**Remembe
r that most
publications
have doi
numbers
now so if
you do not
☒ ☒ ☒ ☐ ☐ ☐ ☐
locate one
on the
original
article,
complete
another
literature
search to
find it.
Format dois
like this:
☒ ☒ ☒ ☐ ☐ ☐ ☐
11

http://doi.or
g...

**Rememb
er this has
changed
from last
semester
Listed in
chronologi
cal order as
☒ ☒ ☒ ☐ ☐ ☐ ☐
they are
referenced
in text
Figures and Tables
Page break
before each ☐ ☐ ☒ ☐ ☐ ☐ ☐
section?
Each
heading is
bolded and
☐ ☐ ☒ ☐ ☐ ☐ ☐
centered
for each
section
If 2 figures
are related,
they are to ☐ ☐ ☐ ☐ ☐ ☐ ☐
be labeled
as A and B.
Captions are
written in
complete
sentences
and single ☐ ☐ ☒ ☐ ☐ ☐ ☐
spaced
starting with
“Figure 1”
Figure
captions
appear after ☐ ☐ ☒ ☐ ☐ ☐ ☐
the figure
Table
captions
appear ☐ ☐ ☒ ☐ ☐ ☐ ☐
before the
figure
All patient ☐ ☐ ☐ ☐ ☐ ☐ ☐
identifying
12

informatio
n is
blocked
and fused
with the
original
image
All table
axis, labels
and
legends are
☐ ☐ ☒ ☐ ☐ ☐ ☐
in Times
New
Roman,
size 12 font
Any DVHs
include
structure
☐ ☐ ☐ ☐ ☐ ☐ ☐
labels
directly on
the DVH
Vertical
lines are
☐ ☐ ☒ ☐ ☐ ☐ ☐
removed
from tables
Single line
spacing
used for
figure and ☐ ☐ ☒ ☐ ☐ ☐ ☐
table
description
s
13

A dosimetric evaluation to determine the impact of using a density override for the
contrast-enhanced spaceOAR for prostate cancer

Asila Lashkeri, B.A., R.T.(T), Reta B.S., R.T.(T)., Ashley Hunzeker, M.S.,
C.M.D., R.T.(T), Nishele Lenards, Ph.D., C.M.D., RT(R)(T), Matt Tobler, C.M.D., RT(T),
F.A.A.M.D.

Medical Dosimetry Program, University of Wisconsin-La Crosse, La Crosse, WI

Introduction
Prostate cancer is the second most common cancer diagnosed in the United States. Rapid
evolving technology and early intervention has allowed for an increased survival rate and early
detection of disease. In the past decade, advancements in the field of radiation therapy with
intensity modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT)
treatment fractionation has improved treatment options available to patients with prostate cancer.
Image guided radiation therapy (IGRT) techniques have assisted clinicians to identify treatment
volumes and sparing organs at risk (OAR) thus allowing for precise treatment to the target
volume.1 Often, the rectal wall may be part of the planning treatment volume (PTV) and may
receive the full prescribed dose. Side effects such as rectal bleeding and proctitis are common
since the rectal wall is often close to the treatment and target volume.
SpaceOAR has been used over the past several years to protect the anterior wall of the
rectum from radiation. The use of a spaceOAR to separate the rectum from the high dose region
helps reduce side effects for the patient. The absorbable gel/spaceOAR is injected, using
ultrasound guidance, into the space confined by the Denonvilliers fascia that lies between the
rectum and the prostate. This creates a barrier between the rectum and the prostate, thus reducing
dose to the OAR and improving patient quality of life.2 In addition to rectal wall sparing,
researchers have also shown that spaceOAR also reduces dose to the bladder and penile bulb
while also providing improved dose coverage.3
Compared to the standard spaceOAR, the new contrast-enhanced spaceOAR has shown
several benefits and revolutionized how these spacers are viewed on a CT scan used for planning
as well as the cone beam computed tomography (CBCT) scans used for daily alignment. These
spacers contain contrast that appear brighter on the CT and CBCT. In the past, spaceOAR has
been difficult to distinguish from the surrounding soft tissue using CT images only due to the
14

inherent lack of soft tissue contrast that CT images provide. Due to the lack of soft tissue
contrast, treatment planning involved fusing a CT scan with a T2 weighted MRI to delineate the
spaceOAR from the rectal wall and the prostate. A new contrast-enhanced spaceOAR contains
contrast that appears brighter on the CT and CBCT. This has shown several benefits. The major
advantage of using the contrast-enhanced spaceOAR is that it would be distinguishable from the
surrounding soft tissue in the CT scan alone and can be accurately contoured without the use of
an MRI, since the contrast would appear bright in the scan. In some cases, patients have fiducials
inserted into their prostate to aid in alignment, setup, and delivery. However, if a patient has
stool in their rectum, the contrast-enhanced spaceOAR not only allows for more separation but
also limits misalignment of fiducials that were placed in the prostate to aid in alignment, set-up,
and treatment delivery. Since it also has enhanced visibility itself on the CBCT, the contrast
enhanced spaceOAR can assist with accurate target matching and ensuring precise treatment
delivery.4
Manufacturer specifications for the attenuation of the contrast-enhanced spaceOAR state
that the Hounsfield unit (HU) value is approximately equal to 300, but the electron density is
1.026 relative to water, and the mass density is 1.03 gm/mL. Currently the density of the
contrast-enhanced spaceOAR is overridden to the density of water since the iodinated spaceOAR
flares up during CT due to the K-edge absorption of photons for iodine in the kV range of the CT
scanner.6 This override is required, since in the MV range, Compton interaction is the most
dominant interaction of photons, and the probability of Compton interactions depends on the
electron density of the materials.  The higher Hounsfield unit (HU) under kilovoltage computed
tomography (kVCT) is due to the added high Z material (Iodine, Z=53) and the property of
photoelectric interaction cross section is proportional to Z3. Iodine will provide about 300 times
more attenuation than water. Dose calculation algorithms in our treatment planning systems use
HU to electron density conversion to account for inhomogeneities in the patient by correlating
the HU value from CT to a corresponding electron density. Often, the density of any contrast
within the patient is overridden because contrast normally would not be present at the time of
treatment since it is only used at the time of simulation to better delineate structures for planning.
If the HU override is not accounted for during planning for the contrast-enhanced spaceOAR it
may impact the dose distribution. Since patients are planned without the override, each plan will
be recalculated with override and the mean dose will be evaluated.5 In addition to the override,
15

the K-edge photoelectric absorption in the KV-range CT scan overestimates the contrast-
enhanced spaceOAR electron density with respect to the CT-to-density curve, as all material on
that curve don’t have a K-edge in that range.
This research is to determine if the enhancement of the contrast on the treatment planning
CT scan is depicting artificially high HU values that could impact dosimetric accuracy during
treatment planning. The impact, if any, of using a density override for the contrast-enhanced
spaceOAR will be determined by calculating the percentage dose difference between override
and no override for the PTV, rectum and bladder. Researchers tested hypotheses that using a
density override will decrease the mean dose by ≤5% to the bladder (H1), rectum (H2), and PTV
(H3).
Materials and Methods
Patient selection and setup
Eighteen patients from a single institution were randomly selected for this research study.
The inclusion criteria were patients with a histologic proven diagnosis of prostate cancer and
patients that had a contrast-enhanced spaceOAR in place. Patients with and without nodal
involvement were included in the selection. Each patient had a CT simulation performed with
appropriate immobilization. To ensure daily reproducibility the patients were simulated supine,
headfirst, with a vac-loc for immobilization of the lower extremity. The Siemens CT simulator
was used to obtain a CT scan of 3.0 mm slice thickness for treatment planning purposes. The CT
scan was sent to the Pinnacle treatment planning system. Of the 18 patients selected, 9 were
treated with stereotactic body radiotherapy (SBRT) technique and 9 patients were treated with
intensity modulated radiation therapy (IMRT) technique.
Contouring
Post simulation, the dataset was exported to Velocity for contouring purposes. PTV
margins were contoured by the physician based on the clinical disease volume. The radiation
oncologist contoured the gross tumor volume (GTV) and the clinical target volume (CTV) with
necessary margins. The planning target volume (PTV) was contoured with additional margins for
optimum tumor coverage. The medical dosimetrist used Velocity, which is a contouring software
for delineation of other important structures such as the bladder, rectum, spaceOAR, bowel bag,
right femoral head, left femoral head, sigmoid colon, and the penile bulb.
Treatment Planning
16

Following target delineation and OAR contouring, the structure set was exported to the
Pinnacle treatment planning system (Version 16.2). The treatment plans were generated using
volumetric modulated arc therapy (VMAT) technique for treatment on the TrueBeam and Varian
Linac. A water-equivalent density override was used for the spaceOAR. Nine patients were
planned using IMRT technique and 9 patients were planned using SBRT technique. The medical
dosimetrist used a density override for the spaceOAR prior to planning. Two to three dynamic
arcs were used with 6X energy for the IMRT plans and 6XFFF for the SBRT plans. The arcs
rotated clockwise and counterclockwise with a collimator angle of 5.0 and 355.0 respectively.
The treatment planning system used the adaptive convolution superposition approach for dose
calculations. Each plan was optimized using planning objectives and achieved OAR constraints.
After dose calculation for the water-equivalent density override, the plans were copied, and the
density override was removed prior to recalculation of the dose without the water-equivalent
density override. Dose volume histograms (DVH) were compared and the mean dose for the
PTV, rectum, and bladder were recorded and analyzed.
Plan Comparison
The objective of this research was to compare the percent dose difference for the PTV,
bladder and rectum, before the density override and after removing the density override on the
spaceOAR. The spaceOAR for each patient was overridden to the density of water and the
results were computed. The mean dose for the rectum, bladder and PTV were recorded. The
density override for the spaceOAR was then removed and the results were recomputed. The
mean dose for the rectum, bladder and PTV were recorded. The collected data was then analyzed
to record the percent dose difference.
Statistical Analysis
The PTV, bladder, and rectum mean dose with the water-equivalent override were
reviewed and analyzed. The PTV, bladder and rectum mean dose without the override were
reviewed and analyzed. The true mean of the percent dose difference based on a 99% confidence
interval was calculated. The confidence interval is based on the range of the values that is
observed in a small sample in which we expect to find the value that accurately reflects the
population.
For each of the 18 patients, the mean dose value for the PTV, bladder and rectum were
observed with and without override. The difference between these two values (no override –
17

override) for the PTV, bladder and rectum were obtained. This difference was then converted to
percentage difference by dividing it by the dose value obtained with the override. Hence our
analysis will provide an outcome stating that we are 99% confident that this population mean
percentage difference is statistically ≤5% or ≥5%.
Results
To determine if the mean of the percentage difference ≤ 5% or ≥5%, a 99% confidence
interval for the true population mean percentage difference was constructed using the formula:
(sample mean – ME, sample mean + ME)
where, ME = margin of error = t(0.005,df=17)*(sample standard deviation)/sqrt (18)

For the Bladder data:

sample mean = 0.0513%,
sample standard deviation = 0.0546%, and hence,
ME (margin of error) = 2.898*0.0546%/sqrt (18) = 0.0373%,
Therefore, the resulting 99% confidence interval is (0.0140%, 0.0886%)
Hence, we are 99% confident that the true population mean percentage difference in
bladder dose between with override and no override is between 0.0140% and 0.0886%. We are
99% confident that this population mean percentage difference is statistically less than 5%.
Hence, the first null hypothesis (H10) that the mean percentage dose difference for the bladder
will increase by ≥5% is rejected.

For the Rectum data:

the sample mean = -0.0156%,
sample standard deviation = 0.0592%, and hence,
ME (margin of error) = 2.898*0.0592%/sqrt (18) = 0.04045%,
Therefore, the resulting 99% confidence interval is (-0.0560%, 0.0249%)
Hence, we are 99% confident that the true population mean percentage difference in
rectum dose between with override and no override is between -0.0560% and 0.0249%. We are
99% confident that this population mean percentage difference is statistically less than 5%.
Hence, the second null hypothesis (H20) that the mean percentage dose difference for the rectum
will increase by ≥5% is rejected.
18

For the PTV data:

sample mean = 0.0081%,
sample standard deviation = 0.0541, and hence,
ME (margin of error) = 2.898*0.0541%/sqrt (18) = 0.0370%,
resulting in a 99% confidence interval of (-0.0289%, 0.0451%)
Hence, we are 99% confident that the true population mean percentage difference in PTV
dose between override and no override is between -0.0286% and 0.0454%. We are 99%
confident that this population mean percentage difference is statistically less than 5%. Hence, the
third null hypothesis (H30) that the mean percentage dose difference for the PTV will increase by
≥5% is rejected.

Acknowledgement
We would like to express our thanks to Dr. Sherwin Toribio of the UWL Statistical
Consulting Center for his contribution to the statistical analysis and interpretation of statistical
results.
19

References
1. Babar M, Ciatto M, Katz A. Dosimetric and clinical outcomes of SpaceOAR in men
undergoing external beam radiation therapy for localized prostate cancer: A Systematic
review. J Med Imaging Radiat Oncol. 2021;65(3):384-397. https://doi.org/10.1111/1754-
9485.13179
2. Atluri P, Desain N, Folkert M, et al. Addition of iodinated contrast to rectal hydrogel
spacer to facilitate MRI-Independent target delineation and treatment planning for
prostate Cancer. Pract Radiat Oncol. 2019;9(6):528-533.
http://doi.org/10.1016/j.prro.2019.05.013
3. Khoo V, Sturt P, Suh Y. The dosimetric advantages of perirectal hydrogel spacer in men
with localized prostate cancer undergoing stereotactic ablative radiotherapy (SABR).
Med Dosim. 2022;47(2):173-176. http://doi.org/10.1016/j.meddos.2022.02.003
4. Desai N, Dubas J, Folkert M, et al. Dosimetric comparison of rectal-sparing capabilities
of rectal balloon vs injectable spacer gel in stereotactic body radiation therapy for
prostate cancer: lessons learned from prospective trials. Med Dosim. 2017;42(4):341-347.
http://doi.org/10.1016/j.meddos.2017.07.002
5. Sudhyadhom A. On the molecular relationship between Hounsfield Unit (HU), mass
density, and electron density in computed tomography (CT). PLoS One. 2020;15(12).
http://doi.org/10.1371/journal.pone.0244861
6. SpaceOAR Vue Hydrogel. Boston Scientific. Published 2022. Accessed July 20, 2022.
https://www.bostonscientific.com/en-US/copyright-notice.html
7. Alexander A, Gagne I, Goulart J, et al. Maximizing rectal dose sparing with hydrogel: A
retrospective planning study. J Appl Clin Med Phys. 2019;20(4):91–98.
https://doi.org/10.1002/acm2.12566
8. Alfieri F, Eade T, Guo L, Kneebone A, Van Gysen K. Feasibility of and rectal dosimetry
improvement with the use of SpaceOAR hydrogel for dose-escalated prostate cancer
radiotherapy. J Med Imaging Radiat Oncol. 2014;58(4):511–516.
https://doi.org/10.1111/1754-9485.12152
9. Dearnaley D, Hall W, Lawton C. Considering benefit and risk before routinely
recommending SpaceOAR. Lancet Oncol. 2021;22(1):11–13.
https://doi.org/10.1016/S1470-2045(20)30639-2
20

10. Aghdam N, Becht K, Collins S, et al. Utilization of iodinated SpaceOAR Vue during
robotic prostate stereotactic body radiation therapy (SBRT) to identify the rectal-prostate
interface and spare the rectum: a case report. Front Oncol. 2020;10.
https://doi.org/10.3389/fonc.2020.607698
11. Armstrong N, Bahl A, Ahmadu C, et al. SpaceOAR hydrogel spacer for reducing
radiation toxicity during radiotherapy for prostate cancer. A systematic review. Urology.
2021;156:74–85. https://doi.org/10.1016/j.urology.2021.05.013
12. Alexander A, Gagne I, Paetkau O. SpaceOAR hydrogel rectal dose reduction prediction
model: a decision support tool. J Appl Clin Med Phys. 2020;21(6):15–25.
https://doi.org/10.1002/acm2.12860
21

Figures

Figure 1: PTV mean dose with and without override for the 18 patients.

Figure 2: Bladder mean dose with and without override for the 18 patients.
22

Figure 3: Rectum mean dose with and without override for the 18 patients.

Figure 4: Estimates of the mean percent difference between mean doses obtained with and
without override. The error bars represent that 99% confidence intervals for the true mean
percent difference. Note that all 3 confidence intervals indicate that the true mean percent
difference for PTV, Bladder, and Rectum are below 5%.
23

Table
Table 1. Comparison of the mean dosimetric data (percent difference) for PTV, Bladder and
Rectum.
PTV BLADDER RECTUM
PTV Percent Bladder Percent Rectum Percent
Difference Difference Difference
Mean 0.0081% 0.0513% -0.0156%

Standard 0.0543% 0.0546% 0.0592%

Deviation (SD)

Margin of 0.037% 0.0373% 0.04045%

Error

Lower Limit -0.028862028% 0.014% -0.05600297%

(LL)

Upper Limit 0.045137972% 0.0886% 0.02489703%

(UL)