Beam Scanning Proton Therapy Research Articles

Online image guided tumour tracking with scanned proton beams: a comprehensive simulation study

Tumour tracking with scanned particle beams potentially requires accurate 3D information on both tumour motion and related density variations. We have previously developed a model-based motion reconstruction method, which allows for the prediction of deformable motions from sparsely sampled surrogate motions tracked via an on-board imaging system (Zhang et al (2013 Phys. Med. Biol. 58 8621)). Here, we investigate the potential effectiveness of tumour tracking for scanned proton beam therapy using such an approach to guide scanned beam tracking, together with the effectiveness of ‘re-tracking’ for reducing residual motion effects due to tracking uncertainties. Three different beam tracking strategies (2D, 2D deformable and 3D) have been applied to three different liver motion cases, with mean magnitudes ranging from 10–20 mm. All simulations have been performed using simulated 4DCTs derived from 4DMRI datasets, whereby inter-breath-cycle motion variability is taken into account. The results show that, without beam tracking, large interplay effects are observed for all motion cases, resulting in CTV D5–95 values of 34.9/58.5/79.4% for the three cases, respectively. These can be reduced to 16.9/18.8/29.1% with 2D tracking, to 15.5/17.9/23.3% with 2D deformable tracking and to 15.1/17.8/21.0% with 3D tracking. Clear ‘inverse interplay’ effects have also been observed in the proximal portion of the field. However, with three-times re-tracking, D5–95 for the largest motions (20 mm) can be reduced to 13.0/12.8% for 2D and 3D tracking, respectively, and ‘hot spots’ resulting from the ‘inverse interplay’ effect can be substantially reduced. In summary, we have found that, for motions over 10 mm, tracking alone cannot fully mitigate motion effects, and can lead to substantially increased doses to normal tissues in the entrance path of the field. However, three-times re-tracking substantially improves the effectiveness of all types of beam tracking, with substantial advantages of 3D over 2D re-tracking only being observed for the largest motion scenario investigated.

Evaluation of the systematic error in using 3D dose calculation in scanning beam proton therapy for lung cancer.

The objective of this study was to evaluate and understand the systematic error between the planned three‐dimensional (3D) dose and the delivered dose to patient in scanning beam proton therapy for lung tumors. Single‐field and multifield optimized scanning beam proton therapy plans were generated for ten patients with stage II‐III lung cancer with a mix of tumor motion and size. 3D doses in CT datasets for different respiratory phases and the time‐weighted average CT, as well as the four‐dimensional (4D) doses were computed for both plans. The 3D and 4D dose differences for the targets and different organs at risk were compared using dose‐volume histogram (DVH) and voxel‐based techniques, and correlated with the extent of tumor motion. The gross tumor volume (GTV) dose was maintained in all 3D and 4D doses, using the internal GTV override technique. The DVH and voxel‐based techniques are highly correlated. The mean dose error and the standard deviation of dose error for all target volumes were both less than 1.5% for all but one patient. However, the point dose difference between the 3D and 4D doses was up to 6% for the GTV and greater than 10% for the clinical and planning target volumes. Changes in the 4D and 3D doses were not correlated with tumor motion. The planning technique (single‐field or multifield optimized) did not affect the observed systematic error. In conclusion, the dose error in 3D dose calculation varies from patient to patient and does not correlate with lung tumor motion. Therefore, patient‐specific evaluation of the 4D dose is important for scanning beam proton therapy for lung tumors.PACS number: 87.55.D

Respiratory Motion Management of Liver Cancer in Uniform Scanning Proton Beam Therapy

Scanning particle beam therapy is an attractive radiation treatment especially due to lower neutron dose and improved target coverage. However, interplay between scanning patterns and inter-field organ motion may results in suboptimal dose within target volume. A simple off-line correction technique for uniform scanning proton beam (USPB) delivery to compensate the interplay between scanning patterns and respiratory motion is investigated.

SU-E-T-363: Experimentally Validated Pencil Beam Scanning Source Model in TOPAS

Purpose: Monte Carlo method can provide the most accurate dose calculation for pencil beam scanning (PBS) proton therapy if the proton sources and particle interaction mechanisms are correct. Methods: TOPAS 1.8, a simulation tool based on Geant4.9.6, was utilized to simulate proton spot profiles. Proton sources, placed at the phantom surface, were modelled with three two-dimensional Gaussian functions to fit measured in-air spot profiles up to 100 mm radius. Simulations were compared with profiles measured using EBT3 film in Solidwater phantoms at various depths from the surface to the end of range for 100, 115, 150, 180, 210 and 225 MeV proton beams with phantom surface locations at 270 mm upstream and at isocentre. Results: Simulation can reproduce one-dimensional integral dose versus radius within 1 mm/1% and two-dimensional profiles within 1 mm out to 0.1% of the central spot dose for all the studied depths of all energies. For two-dimensional 0.01% isodose, simulation can reproduce all 210 MeV proton beam measurements, but cannot predict the diamond-shaped isodose distributions of the 115 MeV beam. When the proton spots are scanned 100 mm off axis, no profile difference can be found between the central axis and the off axis locations for the 210 MeV beam. For the 115 MeV beam, differences of up to 2 mm are observed at the ends of the diamond-shaped 0.01% isodose contour, implying there are lower energy components in the energy spectrum which are less than 4% of the primary energy. Subsequent simulation demonstrates that adopting such an energy spectrum within the source model can improve the distance agreement by 5–6 mm for isodoses below 0.1% near the end of range of the 115 MeV proton beam. Conclusion: Excellent agreement between simulation and measurement validates our PBS source model and the particle interaction mechanism embedded in TOPAS.

TH-C-BRD-11: Robustness of Pencil Beam Scanning Proton Therapy for Pelvic Cancer Under Anatomical Changes

Purpose: Pencil beam scanning (PBS) proton therapy provides excellent dosimetric benefits in pelvic cancer treatment, yet day-to-day anatomical variations in pelvic region tend to cause range uncertainties. This study evaluates the dosimetric robustness under anatomical changes for three PBS intensity-modulated proton therapy (IMPT), IMPT using worstcase robust optimization (thereafter ‘Robust IMPT’), and single-field uniform dose (SFUD), in cervical cancer treatment. Methods: IMPT, Robust IMPT, and SFUD plans using the same beam directions and the same prescription (Rx) were generated on computed tomography (CT) images acquired on the simulation day. The dose from each plan was then recomputed on CT images acquired in subsequent two to five weeks using the same protocol. The weekly CTs were registered to the planning CT based on bony anatomy. Target coverage was considered adequate on each weekly CT if dose to 99% of the internal target volume (D_ITV99%) reached at least 95% of the Rx dose. Statistical analysis was then performed on the 21 weekly CT images available for the 7 enrolled patients. Results: Statistically, IMPT was unable to maintain target coverage (mean D_ITV99% = 90.5% Rx, p = 0.004), and SFUD was able to maintain target coverage (mean D_ITV99% = 98.0% Rx, p = 0.0064), in the weeks following simulation. Robust IMPT was able to improve the robustness of IMPT significantly (p < 0.0001), though its maintenance of target coverage was not statistically significant by the 95% Rx criteria (mean D_ITV99% = 96.0%, p = 0.1677). Conclusion: During the multi-week treatment course with anatomical variations, SFUD is robust in terms of maintaining target coverage while IMPT is not. The worst-case optimized Robust IMPT, assuming ±3.5% range uncertainties, improves the robustness of IMPT under anatomical changes significantly, even though it was not designed to account for anatomical changes by mechanism.

TH-C-BRD-03: Determining the Optimal Collimator Position for Collimated Pencil Beam Scanning Proton Therapy

Purpose: There has been a growing interest in applying collimation to pencil beam scanning (PBS) proton therapy in order to sharpen the lateral dose falloff out of the target, especially at low energies. Currently, there is not a method to optimally determine the collimation position or margin around the target. A uniform margin would not be ideal due to the fact that an incoming symmetric pencil beam, after being intercepted by a collimator near the target boundary, will become asymmetric and experience a lateral shift away from its original spot location, leaving the target insufficiently covered. We demonstrate a method that optimally determines the collimator position on a per-spot basis, in order to maximize target dose while minimizing normal tissue dose. Methods: A library of collimated pencil beams were obtained through Monte Carlo simulation with a collimator placed at varying distances from the central axis of an incoming symmetrical pencil beam of 118 MeV and 5 mm sigma-in-air. Two-dimensional treatment plans were then created using this library of collimated pencil beams. For each spot position in a treatment plan, the collimator position was optimally determined in such a way that the resultant pencil beam maximized the ratio of in-target dosemore » and out-of-target dose. For comparison, un-collimated treatment plans were also computed. Results: The spot-by-spot optimally determined collimator positions allowed the reduction of normal tissue dose while maintaining the same target coverage as un-collimated PBS. Quantitatively, the mean dose outside of the target was reduced by approximately 40% as compared to the plan without collimation. Conclusion: The proposed method determines the optimal collimator position for each spot in collimated PBS proton therapy. The use of a collimator will improve PBS dose distributions achievable today and will continue to be the subject of future investigations.« less

TH-C-BRD-07: Minimizing Dose Uncertainty for Spot Scanning Beam Proton Therapy of Moving Tumor with Optimization of Delivery Sequence

Purpose: Intensity modulated proton therapy (IMPT) has been shown to be able to reduce dose to normal tissue compared to intensity modulated photon radio-therapy (IMRT), and has been implemented for selected lung cancer patients. However, respiratory motion-induced dose uncertainty remain one of the major concerns for the radiotherapy of lung cancer, and the utility of IMPT for lung patients was limited because of the proton dose uncertainty induced by motion. Strategies such as repainting and tumor tracking have been proposed and studied but repainting could result in unacceptable long delivery time and tracking is not yet clinically available. We propose a novel delivery strategy for spot scanning proton beam therapy. Method: The effective number of delivery (END) for each spot position in a treatment plan was calculated based on the parameters of the delivery system, including time required for each spot, spot size and energy. The dose uncertainty was then calculated with an analytical formula. The spot delivery sequence was optimized to maximize END and minimize the dose uncertainty. 2D Measurements with a detector array on a 1D moving platform were performed to validate the calculated results. Results: 143 2D measurements on a moving platform were performed for different delivery sequences of a single layer uniform pattern. The measured dose uncertainty is a strong function of the delivery sequence, the worst delivery sequence results in dose error up to 70% while the optimized delivery sequence results in dose error of <5%. END vs. measured dose uncertainty follows the analytical formula. Conclusion: With optimized delivery sequence, it is feasible to minimize the dose uncertainty due to motion in spot scanning proton therapy.

SU-E-T-133: Dosimetric Impact of Scan Orientation Relative to Target Motion During Spot Scanning Proton Therapy

Purpose: This study seeks to evaluate the dosimetric effects of intra-fraction motion during spot scanning proton beam therapy as a function of beam-scan orientation and target motion amplitude. Method: Multiple 4DCT scans were collected of a dynamic anthropomorphic phantom mimicking respiration amplitudes of 0 (static), 0.5, 1.0, and 1.5 cm. A spot-scanning treatment plan was developed on the maximum intensity projection image set, using an inverse-planning approach. Dynamic phantom motion was continuous throughout treatment plan delivery.The target nodule was designed to accommodate film and thermoluminescent dosimeters (TLD). Film and TLDs were uniquely labeled by location within the target. The phantom was localized on the treatment table using the clinically available orthogonal kV on-board imaging device. Film inserts provided data for dose uniformity; TLDs provided a 3% precision estimate of absolute dose. An inhouse script was developed to modify the delivery order of the beam spots, to orient the scanning direction parallel or perpendicular to target motion.TLD detector characterization and analysis was performed by the Imaging and Radiation Oncology Core group (IROC)-Houston. Film inserts, exhibiting a spatial resolution of 1mm, were analyzed to determine dose homogeneity within the radiation target. Results: Parallel scanning and target motions exhibited reduced target dose heterogeneity, relative to perpendicular scanning orientation. The average percent deviation in absolute dose for the motion deliveries relative to the static delivery was 4.9±1.1% for parallel scanning, and 11.7±3.5% (p<<0.05) for perpendicularly oriented scanning. Individual delivery dose deviations were not necessarily correlated to amplitude of motion for either scan orientation. Conclusions: Results demonstrate a quantifiable difference in dose heterogeneity as a function of scan orientation, more so than target amplitude. Comparison to the analyzed planar dose of a single field hint that multiple-field delivery alters intra-fraction beam-target motion synchronization and may mitigate heterogeneity, though further study is warranted.

SU‐E‐T‐346: Validation of Beam Accuracy of a Gated Spot‐Scanning Proton Therapy System with Real‐Time Tumor‐Tracking at Hokkaido University

Purpose:At Hokkaido University, we have developed a gated spot scanning proton beam therapy system with real‐time tumor‐tracking under collaborative work with Hitachi Ltd. This system has the ability to gate proton beams from the synchrotron, turning the beam on only when the actual positions of inserted fiducial markers monitored by two fluoroscopic X‐ray systems are within the planned positions [Shirato, 2012]. In this research, we validated the accuracy of the proton beams while utilizing external gating signals.Methods:The accuracy of spot positions, spot dose, absolute dose at the center of the SOBP, and range were measured while utilizing external gating signals. The following external gating signals were generated by an arbitrary waveform generator: (1) ON at all times (without gating), (2) an OFF period of 4 s followed by an ON period of 1 s, (3) two ON periods of 0.5 s with a 0.15 s OFF interval, (4) signals recorded during the treatment of real‐time tumor‐tracking X‐ray therapy in Hokkaido University. The spot positions and spot dose were measured by beam monitors in the nozzle. The ranges were measured with a multi‐layer ion chamber made by Hitachi Ltd. The absolute dose was measured with a Farmer ionization chamber and a RFA300 water phantom system.Results:The maximum error of the beam position in the isocenter plane was 0.8 mm without the gating signal and 1.0 mm with the gating signal. The maximum error of the spot dose was 0.0029 MU, below the criterion of 0.0032 MU. The maximum error of the absolute dose was 0.4% and the maximum variation of the range was 0.1 mm.Conclusion:It was confirmed with measurements of the beam that the accuracy of the proton beam met the criteria with external gating signals.This research was supported by the Cabinet Office, Government of Japan and the Japan Society for the Promotion of Science (JSPS) through the Funding Program for World‐Leading Innovative R&amp;D on Science and Technology (FIRST Program), initiated by the Council for Science and Technology Policy (CSTP).

SU-D-BRE-02: Development and Commissioning of A Gated Spot Scanning Proton Beam Therapy System with Real-Time Tumor-Tracking

Purpose: A novel Proton Beam Therapy system has been developed by integrating Real-Time Tumor-Tracking (RTRT) and discrete spot scanning techniques. The system dedicated for spot scanning delivers significant advantages for both clinical and economical points of view. The system has the ability to control dose distribution with spot scanning beams and to gate the beams from the synchrotron to irradiate moving tumors only when the actual positions of them are within the planned position. Methods: The newly designed system consists of a synchrotron, beam transport systems, a compact and rotating gantry system with robotic couch and two orthogonal sets of X-ray fluoroscopes. The fully compact design of the system has been realized by reducing the maximum energy of the beam to 220MeV, corresponding to 30g/cm2 range and the number of circulating protons per synchrotron operation cycle, due to higher beam utilization efficiency in spot scanning. To improve the irradiation efficiency in the integration of RTRT and spot scanning, a new control system has been developed to enable multiple gated irradiation per operation cycle according to the gating signals. After the completion of the equipment installation, beam tests and commissioning has been successfully performed. Results: The basic performances and beam characteristics through the synchrotron accelerator to iso-center have been confirmed and the performance test of the irradiation nozzle and whole system has been appropriately completed. CBCT image has been checked and sufficient quality was obtained. RTRT system has been demonstrated and realized accurate dose distributions for moving targets. Conclusion: The gated spot scanning Proton Beam Therapy system with Real-Time Tumor-Tracking has been developed, successfully installed and tested. The new system enables us to deliver higher dose to the moving target tumors while sparing surrounding normal tissues and to realize the compact design of the system and facility by maximizing the efficiency of proton beam utilization. This research is granted by the Japan Society for the Promotion of Science(JSPS) through the “Funding Program for World-Leading Innovative R&D on Science and Technology(FIRST Program)”, initiated by the Council for Science and Technology Policy(CSTP).

Multifield Optimization Intensity Modulated Proton Therapy for Head and Neck Tumors: A Translation to Practice

We report the first clinical experience and toxicity of multifield optimization (MFO) intensity modulated proton therapy (IMPT) for patients with head and neck tumors. Fifteen consecutive patients with head and neck cancer underwent MFO-IMPT with active scanning beam proton therapy. Patients with squamous cell carcinoma (SCC) had comprehensive treatment extending from the base of the skull to the clavicle. The doses for chemoradiation therapy and radiation therapy alone were 70 Gy and 66 Gy, respectively. The robustness of each treatment plan was also analyzed to evaluate sensitivity to uncertainties associated with variations in patient setup and the effect of uncertainties with proton beam range in patients. Proton beam energies during treatment ranged from 72.5 to 221.8 MeV. Spot sizes varied depending on the beam energy and depth of the target, and the scanning nozzle delivered the spot scanning treatment "spot by spot" and "layer by layer." Ten patients presented with SCC and 5 with adenoid cystic carcinoma. All 15 patients were able to complete treatment with MFO-IMPT, with no need for treatment breaks and no hospitalizations. There were no treatment-related deaths, and with a median follow-up time of 28 months (range, 20-35 months), the overall clinical complete response rate was 93.3% (95% confidence interval, 68.1%-99.8%). Xerostomia occurred in all 15 patients as follows: grade 1 in 10 patients, grade 2 in 4 patients, and grade 3 in 1 patient. Mucositis within the planning target volumes was seen during the treatment of all patients: grade 1 in 1 patient, grade 2 in 8 patients, and grade 3 in 6 patients. No patient experienced grade 2 or higher anterior oral mucositis. To our knowledge, this is the first clinical report of MFO-IMPT for head and neck tumors. Early clinical outcomes are encouraging and warrant further investigation of proton therapy in prospective clinical trials.

Detecting prompt gamma emission during proton therapy: the effects of detector size and distance from the patient

Recent studies have suggested that the characteristics of prompt gammas (PGs) emitted from excited nuclei during proton therapy are advantageous for determining beam range during treatment delivery. Since PGs are only emitted while the beam is on, the feasibility of using PGs for online treatment verification depends greatly on the design of highly efficient detectors. The purpose of this work is to characterize how PG detection changes as a function of distance from the patient as a means of guiding the design and usage of clinical PG imaging detectors. Using a Monte Carlo model (GEANT4.9.4) we studied the detection rate (PGs per incident proton) of a high purity germanium detector for both the total PG emission and the characteristic 6.13 MeV PG emission from 16O emitted during proton irradiation. The PG detection rate was calculated as a function of distance from the isocenter of the proton treatment nozzle for: (1) a water phantom irradiated with a proton pencil beam and (2) a prostate patient irradiated with a scanning beam proton therapy treatment field (lateral field size: ∼6 cm × 6 cm, beam range: 23.5 cm). An analytical expression of the PG detection rate as a function of distance from isocenter, detector size, and proton beam energy was then developed. The detection rates were found to be 1.3 × 10−6 for oxygen and 3.9 × 10−4 for the total PG emission, respectively, with the detector placed 11 cm from isocenter for a 40 MeV pencil beam irradiating a water phantom. The total PG detection rate increased by ∼85 ± 3% for beam energies greater than 150 MeV. The detection rate was found to be approximately 2.1 × 10−6 and 1.7 × 10−3 for oxygen and total PG emission, respectively, during delivery of a single pencil beam during a scanning beam treatment for prostate cancer. The PG detection rate as a function of distance from isocenter during irradiation of a water phantom with a single proton pencil beam was described well by the model of a point source irradiating a cylindrical detector of a known diameter over the range of beam energies commonly used for proton therapy. For the patient studies, it was necessary to divide the point source equation by an exponential factor in order to correctly predict the falloff of the PG detection rate as a function of distance from isocenter.

Radiation Safety Considerations in Proton Aperture Disposal

Beam shaping in scattered and uniform scanned proton beam therapy (PBT) is made commonly by brass apertures. Due to proton interactions, these devices become radioactive and could pose safety issues and radiation hazards. Nearly 2,000 patient-specific devices per year are used at Indiana University Cyclotron Operations (IUCO) and IU Health Proton Therapy Center (IUHPTC); these devices require proper guidelines for disposal. IUCO practice has been to store these apertures for at least 4 mo to allow for safe transfer to recycling contractors. The devices require decay in two staged secure locations, including at least 4 mo in a separate building, at which point half are ready for disposal. At 6 mo, 20-30% of apertures require further storage. This process requires significant space and manpower and should be considered in the design process for new clinical facilities. More widespread adoption of pencil beam or spot scanning nozzles may obviate this issue, as apertures then will no longer be necessary.

Evaluation of the systematic error in using 3D dose calculation in scanning beam proton therapy for lung cancer

Evaluation of the systematic error in using 3D dose calculation in scanning beam proton therapy for lung cancer

Deformable motion reconstruction for scanned proton beam therapy using on-line x-ray imaging

Organ motion is a major problem for any dynamic radiotherapy delivery technique, and is particularly so for spot scanned proton therapy. On the other hand, the use of narrow, magnetically deflected proton pencil beams is potentially an ideal delivery technique for tracking tumour motion on-line. At PSI, our new Gantry is equipped with a Beams Eye View (BEV) imaging system which will be able to acquire 2D x-ray images in fluoroscopy mode during treatment delivery. However, besides precisely tracking motion from BEVs, it is also essential to obtain information on the 3D motion vector throughout the whole region of interest, and any sparsely acquired surrogate motion is generally not sufficient to describe the deformable behaviour of the whole volume in three dimensions. In this study, we propose a method by which 3D deformable motions can be estimated from surrogate motions obtained using this monoscopic imaging system. The method assumes that example motions over a number of breathing cycles can be acquired before treatment for each patient using 4DMRI. In this study, for each of 11 different subjects, 100 continuous breathing cycles have been extracted from extended 4DMRI studies in the liver and then subject specific motion models have been built using principle component analysis (PCA). To simulate treatment conditions, a different set of 30 continuous breathing cycles from the same subjects have then been used to generate a set of simulated 4DCT data sets (so-called 4DCT(MRI) data sets), from which time-resolved digitally reconstructed radiographs (DRRs) were calculated using the BEV geometry for three treatment fields respectively. From these DRRs, surrogate motions from fiducial markers or the diaphragm have been used as a predictor to estimate 3D motions in the liver region for each subject. The prediction results have been directly compared to the ‘ground truth’ motions extracted from the same 30 breath cycles of the originating 4DMRI data set. Averaged over all 11 subjects, and for three field directions, for 99% of predicted positions, median (max) error magnitudes of better than 2.63(5.67) mm can be achieved when fiducial markers was chosen as predictor. Furthermore, three single fields, 4D dose calculations have been performed as a verification tool to evaluate the prediction performance of such a model in the context of scanned proton beam therapy. These show a high similarity between plans considering either PCA predicted motion or ground truth motion, where absolute dose differences of more than 5% (Vdosediff = 5%) occur for the worst field scenarios in only 3.61% (median) or 15.13% (max) of dose calculation points in the irradiated volume. The magnitude of these dose differences were insignificantly dependent on whether surrogate motions were tracked by monoscopic or stereoscopic imaging systems, or whether fiducial markers or diaphragm were chosen as surrogate. This study has demonstrated that on-line deformable motion reconstruction from sparse surrogate motions is feasible, even when using only a monoscopic imaging system. In addition, it has also been found that diaphragm motion can be considered as a good predictor for respiratory deformable liver motion prediction, implying that fiducial markers might not be compulsory if used in conjunction with a patient specific PCA based model.

Pencil Beam Scanning (PBS) Proton Therapy in a Fixed-Beam Room for Treatment of Pediatric Brain Tumors

Pencil Beam Scanning (PBS) Proton Therapy in a Fixed-Beam Room for Treatment of Pediatric Brain Tumors

TU-A-108-05: Quantification and Prediction of Dose Variation in Scanning Beam Proton Therapy From Setup and Anatomical Change for Single-Field, Multi-Field, and Robustly Optimized Plans

Purpose: The purpose of this study is two-fold: 1) to study proton dose variation due to weekly patient setup and anatomy change; and 2) to evaluate the effectiveness of robustness optimization and robustness evaluation techniques. Methods: For a given patient, single-field optimized (SFO), multi-field optimized (MFO) and multi-field optimized with robustness constrains (MFO-Robust) plans were generated on a simulation CT (CT0). The robustness of the plans was evaluated on CT0 with a statistical technique to compute standard deviation of the dose-volume histogram (SD-DVH) of the target volumes and critical structures for 600 combinations of setup and range uncertainties. The original plans were recalculated on subsequent weekly CTs (CTn), and the dose distributions on weekly CTs were deformed onto CT0 using the Velocity (Velocity Medical Solutions) software. The DVHs of weekly doses, as well as the accumulated dose were compared on CT0 with the anticipated SD-DVH variations predicted by the statistical plan robustness evaluation system. Results: The mean standard deviation of weekly doses for voxels within the GTV is <2%, for all techniques, the standard deviation of dose difference between the accumulated dose and the planned dose is <1% in GTV for all techniques. The DVH deviations of weekly and accumulated doses were within the 2SD-DVH confidence interval. Conclusion: This study quantifies the weekly variation of the patient dose, and the accumulated dose variation due to setup uncertainty and anatomy change. The SD-DVH, which is calculated at the time of planning, could be a good predictor of dose variation over the course of treatment.

Rectal dose-volume differences for scanning proton beam therapy with or without an endorectal balloon for the treatment of prostate cancer.

243 Background: Endorectal balloons (ERB) are routinely used in proton radiation for prostate cancer (PCa). The dosimetric implications, however, in conjunction with scanning proton beam therapy (SPT) have not been studied. We sought to describe dose-volume values with the use of an ERB vs no ERB for SPT for PCa. Methods: We analyzed 10 patients with localized PCa. Each patient underwent two CT simulations, one with a water-filled ERB (50-60 ml) and one with no ERB. For 8 patients, the prostate and proximal 1 cm of the seminal vesicles was the clinical target volume (CTV), with the prostate only as CTV for 2 patients. We defined 3 structures: rectum (R), anterior rectal wall (ARW) as a 3 mm rim of the anterior half of the rectum, and AR-CTV as the ARW only on slices with a contoured CTV. SPT plans were created in both cases for each patient, with the creation of a scanning target volume (STV), which expanded the CTV by 6 mm in all dimensions except 4 mm posteriorly and 12 mm laterally. Two opposed lateral beams were used to plan to the STV. Total dose was 78 Co-60 Gy equivalent in 39 fractions, to cover 95% of the STV. RBE was 1.1. We compared the dose-volume values for the R, ARW, and AR-CTV between the two arms. Results: The ERB significantly increased the R volume for all cases (61 ± 11 ml vs 105 ± 10 ml (p&lt;0.01)). Rectal volumes radiated for all cases: V10, 55%; V50, 23%; and V70, 11%. The ERB significantly decreased the R volume radiated for all dose levels V5-V82 (p&lt;0.05). The absolute difference was larger at low dose levels (8% at V10) and intermediate dose levels (5% at V50) compared to high dose levels (3% at V70). For the ARW, the ERB did not significantly change the volume radiated at any dose level. For the AR-CTV, the ERB significantly decreased the volume radiated for dose levels V20-V60 (p&lt;0.05). Conclusions: The ERB provided a significant decrease in R volume radiated at all dose levels, and significantly decreased the AR-CTV volume, which represents a high risk volume, radiated at intermediate dose levels. Rectal doses with SPT, however, were low whether using an ERB or not. In the setting of the low rectal doses delivered, further study regarding the clinical benefit is warranted.

Use of treatment log files in spot scanning proton therapy as part of patient-specific quality assurance

The purpose of this work was to assess the monitor unit (MU) values and position accuracy of spot scanning proton beams as recorded by the daily treatment logs of the treatment control system, and furthermore establish the feasibility of using the delivered spot positions and MU values to calculate and evaluate delivered doses to patients. To validate the accuracy of the recorded spot positions, the authors generated and executed a test treatment plan containing nine spot positions, to which the authors delivered ten MU each. The spot positions were measured with radiographic films and Matrixx 2D ion-chambers array placed at the isocenter plane and compared for displacements from the planned and recorded positions. Treatment logs for 14 patients were then used to determine the spot MU values and position accuracy of the scanning proton beam delivery system. Univariate analysis was used to detect any systematic error or large variation between patients, treatment dates, proton energies, gantry angles, and planned spot positions. The recorded patient spot positions and MU values were then used to replace the spot positions and MU values in the plan, and the treatment planning system was used to calculate the delivered doses to patients. The results were compared with the treatment plan. Within a treatment session, spot positions were reproducible within ±0.2 mm. The spot positions measured by film agreed with the planned positions within ±1 mm and with the recorded positions within ±0.5 mm. The maximum day-to-day variation for any given spot position was within ±1 mm. For all 14 patients, with ∼1 500 000 spots recorded, the total MU accuracy was within 0.1% of the planned MU values, the mean (x, y) spot displacement from the planned value was (-0.03 mm, -0.01 mm), the maximum (x, y) displacement was (1.68 mm, 2.27 mm), and the (x, y) standard deviation was (0.26 mm, 0.42 mm). The maximum dose difference between calculated dose to the patient based on the plan and recorded data was within 2%. The authors have shown that the treatment log file in a spot scanning proton beam delivery system is precise enough to serve as a quality assurance tool to monitor variation in spot position and MU value, as well as the delivered dose uncertainty from the treatment delivery system. The analysis tool developed here could be useful for assessing spot position uncertainty and thus dose uncertainty for any patient receiving spot scanning proton beam therapy.

Comparison of Scanning Beam Proton Therapy (SBPT) to Intensity Modulated X-ray Therapy (IMRT) for Postoperative Salvage Treatment of Prostate Cancer Patients

To determine if significant normal tissue sparing without sacrificing target coverage can be achieved using scanning beam proton therapy (SBPT) compared to intensity modulated x-ray therapy (IMRT) for prostate cancer patients treated for salvage after prostatectomy.