Passive Scattering Proton Therapy Plans Research Articles

Radiation-Induced Lymphopenia Risks of Photon Versus Proton Therapy for Esophageal Cancer Patients.

PurposeTo assess possible differences in radiation-induced lymphocyte depletion for esophageal cancer patients being treated with the following 3 treatment modalities: intensity-modulated radiation therapy (IMRT), passive scattering proton therapy (PSPT), and intensity-modulated proton therapy (IMPT).Methods and MaterialsWe used 2 prediction models to estimate lymphocyte depletion based on dose distributions. Model I used a piecewise linear relationship between lymphocyte survival and voxel-by-voxel dose. Model II assumes that lymphocytes deplete exponentially as a function of total delivered dose. The models can be fitted using the weekly absolute lymphocyte counts measurements collected throughout treatment. We randomly selected 45 esophageal cancer patients treated with IMRT, PSPT, or IMPT at our institution (15 per modality) to demonstrate the fitness of the 2 models. A different group of 10 esophageal cancer patients who had received PSPT were included in this study of in silico simulations of multiple modalities. One IMRT and one IMPT plan were created, using our standards of practice for each modality, as competing plans to the existing PSPT plan for each patient. We fitted the models by PSPT plans used in treatment and predicted absolute lymphocyte counts for IMRT and IMPT plans.ResultsModel validation on each modality group of patients showed good agreement between measured and predicted absolute lymphocyte counts nadirs with mean squared errors from 0.003 to 0.023 among the modalities and models. In the simulation study of IMRT and IMPT on the 10 PSPT patients, the average predicted absolute lymphocyte count (ALC) nadirs were 0.27, 0.35, and 0.37 K/μL after IMRT, PSPT, and IMPT treatments using Model I, respectively, and 0.14, 0.22, and 0.33 K/μL using Model II.ConclusionsProton plans carried a lower predicted risk of lymphopenia after the treatment course than did photon plans. Moreover, IMPT plans outperformed PSPT in terms of predicted lymphocyte preservation.

Dose-Volume Comparison of IMRT and PSPT Treatment Plans for Early-Stage Glottic Cancer.

PurposeTo clarify the dose distribution characteristics for early-stage glottic cancer by comparing the dose distribution between intensity-modulated radiation therapy (IMRT) and passive scattering proton therapy (PSPT) and to examine the usefulness of PSPT for early-stage glottic cancer.Materials and MethodsComputed tomography datasets of 8 patients with T1-2 glottic cancer who had been treated by PSPT were used to create an IMRT plan in Eclipse with 7 fields and a PSPT plan in XiO-M with 2 fields. Organs at risk (OARs) included the carotid arteries, arytenoids, inferior constrictor muscles, strap muscles, thyroid cartilage, cricoid cartilage, and spinal cord. The prescription dose was 66 GyRBE in 33 fractions to the planning target volume (PTV). All plans were optimized such that 95% of the PTV received 90% of the prescription dose considering that the skin was slightly spared.ResultsThe superiority of the PSPT was confirmed in all OARs. In the PSPT, the dose to the contralateral carotid artery and the spinal cord, which is slightly distant from the PTV, was dramatically reduced while maintaining the dose distribution uniformity of the PTV by comparison with IMRT.ConclusionPSPT for early-stage glottic cancer resulted in good target dose homogeneity and significantly spared the OARs as compared with the IMRT. PSPT is expected to be effective in reducing late effects and particularly useful for young people.

Hydrogel Spacer Reduces Rectal Dose during Proton Therapy for Prostate Cancer: A Dosimetric Analysis.

Proton therapy for prostate cancer may reduce bowel dose and risk of bowel symptoms relative to photon-based methods. Here, we determined the effect of using a biodegradable, injectable hydrogel spacer on rectal dose on plans for treating prostate cancer with intensity-modulated proton therapy (IMPT) or passive scattering proton therapy (PSPT). Pairs of IMPT and PSPT plans for 9 patients were created from fused computed tomography/magnetic resonance imaging scans obtained before and after spacer injection. Calculated values of rectal V40, V60, V70, V80, and maximum dose (Dmax) were compared with Wilcoxon signed rank tests. Displacements at the base (BP), midgland (MP), and apex (AP) of the prostate relative to the anterior rectal wall with the spacer in place were averaged for each patient and correlated with V70 by using linear regression models. The presence of a spacer reduced all dosimetric parameters for both PSPT and IMPT, with the greatest difference in V70, which was 81.1% lower for PSPT-with-spacer than for IMPT-without-spacer. Median displacements at BP, MP, and AP were 12 mm (range 7-19), 2 mm (range 0-4), and 1 mm (range 0-5) without the spacer and 19 mm (range 12-23), 10 mm (range 8-16), and 7 mm (range 2-12) with the spacer. Modest linear trends were noted between rectal V70 and displacement for IMPT-with-spacer and PSPT-with-spacer. When displacement was ≥8 mm, V70 was ≤5.1% for IMPT-with-spacer and PSPT-with-spacer. Use of biodegradable hydrogel spacers for prostate cancer treatment provides a significant reduction of radiation dose to the rectum with proton therapy. Significant reductions in rectal dose occurred in both PSPT and IMPT plans, with the greatest reduction for IMPT-with-spacer relative to PSPT alone. Prospective studies are ongoing to assess the clinical impact of reducing rectal dose with hydrogel spacers.

Effect of anatomical change on dose distribution during radiotherapy for maxillary sinus carcinoma: passive scattering proton therapy versus volumetric-modulated arc therapy.

Objective:Maxillary sinus carcinomas are anatomically situated next to many organs at risk (OARs), and anatomical change is often observed during radiotherapy. We analyzed the effect of anatomical change on dose distribution of passive scattering proton therapy (PSPT) and volumetric-modulated arc therapy (VMAT) for 20 patients.Methods:The first plans were generated based on the first CT images. The second CT images were acquired after 3 weeks, and the second plans were generated by copying the first plans to the second CT images. The effect of anatomical change was estimated by comparing both plans.Results:Target volume change was observed in all cases, however, the influence on dose coverage of clinical target volume tended to be small. Alternatively, the doses to almost all OARs were increased. In particular, the increase in the dose to brainstem (p < 0.001) and optic chiasm (p < 0.001) was significantly higher in the second PSPT plan than in the first PSPT plan. Although PSPT is sensitive to anatomical change, the dose to OARs remained significantly lower in PSPT plans than that in VMAT plans.Conclusion:PSPT was confirmed to be more effective than VMAT even the effect of anatomical change was taken into account. Therefore, it is expected that the contralateral vision can be preserved reliably while optimal target coverage is provided.Advances in knowledge:PSPT allowed significant sparing of OARs even in the result of the second plans affected by the anatomical change. PSPT offers benefits over VMAT in reducing dose to several OARs.

SU‐F‐T‐150: Comparing Normal Tissue Irradiated Volumes for Proton Vs. Photon Treatment Plans On Lung Patients

Purpose:The aim of this work is to compare the “irradiated volume” (IRV) of normal tissues receiving 5, 20, 50, 80 and 90% or higher of the prescription dose with passively scattered proton therapy (PSPT) vs. IMRT of lung cancer patients. The overall goal of this research is to understand the factors affecting outcomes of a randomized PSPT vs. IMRT lung trial.Methods:Thirteen lung cancer patients, selected randomly, were analyzed. Each patient had PSPT and IMRT 74 Gy (RBE) plans meeting the same normal tissue constraints generated. IRVs were created for pairs of IMRT and PSPT plans on each patient. The volume of iGTV, (respiratory motion‐incorporated GTV) was subtracted from each IRV to create normal tissue irradiated volume IRVNT. The average of IRVNT DVHs over all patients was also calculated for both modalities and inter‐compared as were the selected dose‐volume indices. Probability (p value) curves were calculated based on the Wilcoxon matched‐paired signed‐rank test to determine the dose regions where the statistically significant differences existed.Results:As expected, the average 5, 20 and 50% IRVNT's for PSPT was found to be significantly smaller than for IMRT (p &lt; 0.001, 0.01, and 0.001 respectively). However, the average 90% IRVNT for PSPT was greater than for IMRT (p = 0.003) presumably due to larger penumbra of protons and the long range of protons in lower density media. The 80% IRVNT for PSPT was also larger but not statistically distinguishable (p = .224).Conclusion:PSPT modality has smaller irradiated volume at lower doses, but larger volume at high doses. A larger cohort of lung patients will be analyzed in the future and IRVNT of patients treated with PSPT and IMRT will be compared to determine if the irradiated volumes (the magnitude of “dose bath”) correlate with outcomes.

Perturbation of water-equivalent thickness as a surrogate for respiratory motion in proton therapy.

Respiratory motion is traditionally assessed using tumor motion magnitude. In proton therapy, respiratory motion causes density variations along the beam path that result in uncertainties of proton range. This work has investigated the use of water‐equivalent thickness (WET) to quantitatively assess the effects of respiratory motion on calculated dose in passively scattered proton therapy (PSPT). A cohort of 29 locally advanced non‐small cell lung cancer patients treated with 87 PSPT treatment fields were selected for analysis. The variation in WET (ΔWET) along each field was calculated between exhale and inhale phases of the simulation four‐dimensional computed tomography. The change in calculated dose (ΔDose) between full‐inhale and full‐exhale phase was quantified for each field using dose differences, 3D gamma analysis, and differential area under the curve (ΔAUC) analysis. Pearson correlation coefficients were calculated between ΔDose and ΔWET. Three PSPT plans were redesigned using field angles to minimize variations in ΔWET and compared to the original plans. The median ΔWET over 87 treatment fields ranged from 1‐9 mm, while the ΔWET 95th percentile value ranged up to 42 mm. The ΔWET was significantly correlated (p<0.001) to the ΔDose for all metrics analyzed. The patient plans that were redesigned using ΔWET analysis to select field angles were more robust to the effects of respiratory motion, as ΔAUC values were reduced by more than 60% in all three cases. The tumor motion magnitude alone does not capture the potential dosimetric error due to respiratory motion because the proton range is sensitive to the motion of all patient anatomy. The use of ΔWET has been demonstrated to identify situations where respiratory motion can impact the calculated dose. Angular analysis of ΔWET may be capable of designing radiotherapy plans that are more robust to the effects of respiratory motion.PACS number(s): 87.55.‐x

Impact of Spot Size and Beam-Shaping Devices on the Treatment Plan Quality for Pencil Beam Scanning Proton Therapy

This study aimed to assess the clinical impact of spot size and the addition of apertures and range compensators on the treatment quality of pencil beam scanning (PBS) proton therapy and to define when PBS could improve on passive scattering proton therapy (PSPT). The patient cohort included 14 pediatric patients treated with PSPT. Six PBS plans were created and optimized for each patient using 3 spot sizes (∼12-, 5.4-, and 2.5-mm median sigma at isocenter for 90- to 230-MeV range) and adding apertures and compensators to plans with the 2 larger spots. Conformity and homogeneity indices, dose-volume histogram parameters, equivalent uniform dose (EUD), normal tissue complication probability (NTCP), and integral dose were quantified and compared with the respective PSPT plans. The results clearly indicated that PBS with the largest spots does not necessarily offer a dosimetric or clinical advantage over PSPT. With comparable target coverage, the mean dose (Dmean) to healthy organs was on average 6.3% larger than PSPT when using this spot size. However, adding apertures to plans with large spots improved the treatment quality by decreasing the average Dmean and EUD by up to 8.6% and 3.2% of the prescribed dose, respectively. Decreasing the spot size further improved all plans, lowering the average Dmean and EUD by up to 11.6% and 10.9% compared with PSPT, respectively, and eliminated the need for beam-shaping devices. The NTCP decreased with spot size and addition of apertures, with maximum reduction of 5.4% relative to PSPT. The added benefit of using PBS strongly depends on the delivery configurations. Facilities limited to large spot sizes (>∼8 mm median sigma at isocenter) are recommended to use apertures to reduce treatment-related toxicities, at least for complex and/or small tumors.

SU‐E‐T‐628: Predicted Risk of Post‐Irradiation Cerebral Necrosis in Pediatric Brain Cancer Patients: A Treatment Planning Comparison of Proton Vs. Photon Therapy

Purpose:Post‐irradiation cerebral necrosis (PICN) is a severe late effect that can Result from brain cancers treatment using radiation therapy. The purpose of this study was to compare the treatment plans and predicted risk of PICN after volumetric modulated arc therapy (VMAT) to the risk after passively scattered proton therapy (PSPT) and intensity modulated proton therapy (IMPT) in a cohort of pediatric patients.Methods:Thirteen pediatric patients with varying age and sex were selected for this study. A clinical treatment volume (CTV) was constructed for 8 glioma patients and 5 ependymoma patients. Prescribed dose was 54 Gy over 30 fractions to the planning volume. Dosimetric endpoints were compared between VMAT and proton plans. The normal tissue complication probability (NTCP) following VMAT and proton therapy planning was also calculated using PICN as the biological endpoint. Sensitivity tests were performed to determine if predicted risk of PICN was sensitive to positional errors, proton range errors and selection of risk models.Results:Both PSPT and IMPT plans resulted in a significant increase in the maximum dose and reduction in the total brain volume irradiated to low doses compared with the VMAT plans. The average ratios of NTCP between PSPT and VMAT were 0.56 and 0.38 for glioma and ependymoma patients respectively and the average ratios of NTCP between IMPT and VMAT were 0.67 and 0.68 for glioma and ependymoma plans respectively. Sensitivity test revealed that predicted ratios of risk were insensitive to range and positional errors but varied with risk model selection.Conclusion:Both PSPT and IMPT plans resulted in a decrease in the predictive risk of necrosis for the pediatric plans studied in this work. Sensitivity analysis upheld the qualitative findings of the risk models used in this study, however more accurate models that take into account dose and volume are needed.

Predictive Risk of Radiation Induced Cerebral Necrosis in Pediatric Brain Cancer Patients after VMAT Versus Proton Therapy.

Cancer of the brain and central nervous system (CNS) is the second most common of all pediatric cancers. Treatment of many of these cancers includes radiation therapy of which radiation induced cerebral necrosis (RICN) can be a severe and potentially devastating side effect. Risk factors for RICN include brain volume irradiated, the dose given per fraction and total dose. Thirteen pediatric patients were selected for this study to determine the difference in predicted risk of RICN when treating with volumetric modulated arc therapy (VMAT) compared to passively scattered proton therapy (PSPT) and intensity modulated proton therapy (IMPT). Plans were compared on the basis of dosimetric endpoints in the planned treatment volume (PTV) and brain and a radiobiological endpoint of RICN calculated using the Lyman-Kutcher-Burman probit model. Uncertainty tests were performed to determine if the predicted risk of necrosis was sensitive to positional errors, proton range errors and selection of risk models. Both PSPT and IMPT plans resulted in a significant increase in the maximum dose to the brain, a significant reduction in the total brain volume irradiated to low doses, and a significant lower predicted risk of necrosis compared with the VMAT plans. The findings of this study were upheld by the uncertainty analysis.

Intensity Modulated Proton Therapy for Craniospinal Irradiation: Organ-at-Risk Exposure and a Low-Gradient Junctioning Technique

To compare field junction robustness and sparing of organs at risk (OARs) during craniospinal irradiation (CSI) using intensity modulated proton therapy (IMPT) to conventional passively scattered proton therapy (PSPT). Ten patients, 5 adult and 5 pediatric patients, previously treated with PSPT-based CSI were selected for comparison. Anterior oblique cranial fields, using a superior couch rotation, and posterior spinal fields were used for IMPT planning. To facilitate low-gradient field junctioning along the spine, the inverse-planning IMPT technique was divided into 3 stages. Dose indices describing target coverage and normal tissue dose, in silico error modeling, and film dosimetry were used to assess plan quality. Field junction robustness along the spine was improved using the staged IMPT planning technique, reducing the worst case impact of a 4-mm setup error from 25% in PSPT to <5% of prescription dose. This was verified by film dosimetry for clinical delivery. Exclusive of thyroid dose in adult patients, IMPT plans demonstrated sparing of organs at risk as good or better than PSPT. Coverage of the cribriform plate for pediatric (V95% [percentage of volume of the target receiving at least 95% of the prescribed dose]; 87 ± 11 vs 92 ± 7) and adult (V95%; 94 ± 7 vs 100 ± 1) patients and the clinical target in pediatric (V95%; 98 ± 2 vs 100 ± 1) and adult (V95%; 100 ± 1 vs 100 ± 1) patients for PSPT and IMPT plans, respectively, were comparable or improved. For adult patients, IMPT target dose inhomogeneity was increased, as determined by heterogeneity index (HI) and inhomogeneity coefficient (IC). IMPT lowered maximum spinal cord dose, improved spinal dose homogeneity, and reduced exposure to other OARs. IMPT has the potential to improve CSI plan quality and the homogeneity of intrafractional dose at match lines. The IMPT approach developed may also simplify treatments and reduce workload per patient relative to PSPT.

TH-C-BRD-08: Reducing the Effect of Respiratory Motion On the Delivered Dose in Proton Therapy Through Proper Field Angle Selection

Purpose: This work investigated a novel planning strategy of selecting radiotherapy beam angles that minimizes the change in water equivalent thickness (dWET) during respiration in order to reduce the effects of respiratory motion in passively scattered proton therapy (PSPT). Methods: In a clinical trial treating locally-advanced lung cancer with proton therapy, 2–4 co-planar beams were previously selected by dosimetrists in the design of physician-approved PSPT treatment plans. The authors identified a cohort of patients in which respiratory motion affected the planned PSPT dose delivery. For this cohort, this work analyzed dWET during respiration over a 360 degree arc of potential treatment angles around the patient: the dWET was defined as the difference in WET between the full-exhale (T50) and full-inhale (T0) phases of the simulation 4DCT. New PSPT plans were redesigned by selecting new beam angles that demonstrated significant reduction in the value of dWET. Between the T50 and T0 phases, the root-mean-square deviation of dose and the change in dose-volume histogram curves (dAUC) for anatomical structures were calculated to compare the original to dWET reduction plans. Results: To date, three plans were retrospectively redesigned based on dWET analysis. In the dWET reduction plan, the root mean square dose (T50-T0) was reduced by 15–35% and the DVH dAUC values were reduced by more than 60%.The PSPT plans redesigned by selecting appropriate field angles to minimize dWET demonstrated less dosimetric variation due to respiration. Conclusion: We have introduced the use of a new metric to quantify respiratory motion in proton therapy: dWET. The use of dWET allows us to minimize the impact of respiratory motion of the entire anatomy in the beam path. This work is a proof of principle that dWET could suggest field angles in proton therapy that are more robust to the effects of respiratory motion.

SU‐E‐T‐493: Analysis of the Impact of Range and Setup Uncertainties On the Dose to Brain Stem and Whole Brain in the Passively Scattered Proton Therapy Plans

Purpose:To quantify the impact of range and setup uncertainties on various dosimetric indices that are used to assess normal tissue toxicities of patients receiving passive scattering proton beam therapy (PSPBT).Methods:Robust analysis of sample treatment plans of six brain cancer patients treated with PSPBT at our facility for whom the maximum brain stem dose exceeded 5800 CcGE were performed. The DVH of each plan was calculated in an Eclipse treatment planning system (TPS) version 11 applying ±3.5% range uncertainty and ±3 mm shift of the isocenter in x, y and z directions to account for setup uncertainties. Worst‐case dose indices for brain stem and whole brain were compared to their values in the nominal plan to determine the average change in their values. For the brain stem, maximum dose to 1 cc of volume, dose to 10%, 50%, 90% of volume (D10, D50, D90) and volume receiving 6000, 5400, 5000, 4500, 4000 CcGE (V60, V54, V50, V45, V40) were evaluated. For the whole brain, maximum dose to 1 cc of volume, and volume receiving 5400, 5000, 4500, 4000, 3000 CcGE (V54, V50, V45, V40 and V30) were assessed.Results:The average change in the values of these indices in the worst scenario cases from the nominal plan were as follows. Brain stem; Maximum dose to 1 cc of volume: 1.1%, D10: 1.4%, D50: 8.0%, D90:73.3%, V60:116.9%, V54:27.7%, V50: 21.2%, V45:16.2%, V40:13.6%,Whole brain; Maximum dose to 1 cc of volume: 0.3%, V54:11.4%, V50: 13.0%, V45:13.6%, V40:14.1%, V30:13.5%.Conclusion:Large to modest changes in the dosiemtric indices for brain stem and whole brain compared to nominal plan due to range and set up uncertainties were observed. Such potential changes should be taken into account while using any dosimetric parameters for outcome evaluation of patients receiving proton therapy.

Study of Robustness of Passive Scattering Proton Therapy Plans for Targets in Lung and Comparison With IMRT Plans

Proton therapy plans are often thought to be highly sensitive to range and setup uncertainties. This study investigated robustness of passive scattering proton therapy (PSPT) plans used for treating targets of lung cancer patients and compared the worse-case scenario plans with the nominal proton plans as well as with the corresponding IMRT plans.

TH‐A‐116‐03: Photon and Proton Radiotherapy of the Lung Would Benefit From 4D Dose Calculation Techniques

Purpose: To compare the effects of respiratory motion by calculating four‐dimensional (4D) dose accumulation on proton and photon radiotherapy plans for a stage III lung cancer cohort.Methods and Materials: This study used passively scattered proton therapy (PSPT) and photon intensity modulated radiotherapy (IMRT) plans designed to meet the same criteria for an ongoing clinical trial. For 20 patients, 4D dose evaluation was calculated on both the PSPT and IMRT plans by accumulating individual phase dose using an intensity‐based in‐house deformable image registration algorithm. The resulting 4D dose accumulation method was compared against current standard of three dimensional (3D) dose as calculated on the average CT. Results: Both proton and photon plans demonstrated dosimetric differences when accounting for respiratory motion using 4D dose calculation methods. Reported 4D‐3D values are mean plus one standard deviation. 4D‐3D difference in PTV 95% dose coverage was &gt;2% for 5 IMRT (0.5±1.1Gy) and 4 PSPT plans (0.5±0.8Gy). The structural doses most affected by respiratory motion were normal structures distal to the tumor, such as esophagus V65 (IMRT: −0.5±1.2Gy, PSPT: −0.4±1.4), mean heart (IMRT: − 0.4±0.6 Gy, PSPT: −0.3±0.9 Gy) and spinal cord maximum (IMRT: 0.0±0.2Gy, PSPT: 1.5±2.9Gy). No correlations were found between tumor motion and the change in 4D dose difference for any lung, heart, or spine dose‐volume index. Conclusions: The use of 4D dose evaluation techniques at time of treatment planning revealed small but significant respiratory motion induced deviations from the 3D planned dose for both photon and proton therapy. In both modalities, differences between 3D and 4D dose distributions are patient dependent; no population trends were found correlating dose differences to the extent of tumor motion. The implementation of 4D dose calculation methods for proton and photon lung cancer radiotherapy plans may help identify patients for whom respiratory motion alters the planned dose distribution. This project is supported by grant P01CA021239 from the National Cancer Institute.

MO‐G‐137‐05: Improving Passive Scattering Proton Therapy Plan Quality by Optimizing Compensator Parameters

Purpose: To demonstrate the importance of optimizing compensator parameters in passive scattering proton therapy (PSPT). Method:We examined the plans of four patients treated for lung tumors at MD Anderson Cancer Center. Comparable IMRT and PSPT plans had been created for each of these patients. The clinical PSPT plans were calculated using 5 mm drill bit compensators with smearing values of 0.5 to 0.9 cm. Two new plans were created for each patient: one with a smearing value of 0 cm and a second with 0 cm smearing and smooth compensators. The prescribed isodose line of each plan was changed so that PTV D95 was equal in a given patient's plans and robustness analysis was performed to evaluate the impact of the compensator changes. A plan was considered robust if ITV D95 remained greater than 95% of the prescribed dose in the worst case scenario for target coverage. The robust plan with altered compensator parameters and most improved normal tissue sparing was considered to be the compensator optimized plan. Results: Mean lung dose for the 4 patients is 19.8, 12.7, 11.9 and 12.4 Gy in the compensator optimized plans compared to 21.8, 14.2, 12.9 and 13.6 Gy in the clinical plans; esophagus V60 is 39.2%, 13.4%, 7.7% and 17.7% compared to 48.6%, 18.1%, 11.6% and 20.7%; mean heart dose is 23.3, 1.2, 8.2 and 4.6 Gy compared to 24.7, 2.4, 9.5 and 8.3 Gy. Conclusion: Robustness analysis allows reduction of the smearing parameter while keeping confidence that the plan is robust against range and setup uncertainties. Compensator parameters should be individually optimized if PSPT plans are to display maximum advantage over IMRT plans in terms of dose volume data.

SU‐E‐T‐275: Voxelized Second Cancer Risk Calculation — Comparison of Proton and Photon Radiotherapies for Hodgkin Lymphoma

Purpose: The purpose of this study was to compare the risk of developing a second lung or breast cancer for a female Hodgkin Lymphoma patient treated with passively scattered proton therapy (PSPT) and photon intensity modulated radiotherapy (IMRT). Particular objectives of this work were to fully account for stray dose, perform voxel by voxel risk calculations, and to visually display risk in a manner analogous to dose visualization used in commercial treatment planning systems (CTPS). Methods: Clinically approved PSPT and IMRT treatment plans were designed using a CTPS and prescribed 36 Gy to the target volume. Neutron and stray photon dose were calculated using an in house Monte Carlo code and a TLD measurement fitted analytical model for PSPT and IMRT, respectively. For lung and breast, therapeutic and stray doses were summed and input into an in‐house program that calculates Excess Absolute Risk (EAR) per voxel in the patient based on the RadRAT risk model. The radiation weighting factor (Wr) varied for neutron doses (Wr =10 and 30) to account for biological uncertainties. Results: Neutron equivalent doses added an additional 3% (Wr =10)/9% (Wr =30) of the prescribed dose to the CTV and near field organs. Scatter dose added an additional 5% (Wr =10 )/15% (Wr =30) of the prescribed dose to organ portions far out of field. PSPT registered a lower EAR compared to IMRT except for lung when Wr =30. Larger differences were seen in low dose regions of organs. Conclusion: EAR was lower for PSPT versus IMRT unless neutron Wr values were very high, e.g.&gt; ∼20. More work incorporating uncertainties must be done before definitive answers are determined. In the future, similar types of risk visualization tools could be incorporated into treatment plan analysis to prospectively select plans with the lowest predicted risk of second cancers. This research was supported in part, by the National Cancer Institute award 1R01CA131463‐01A1 (W.D. Newhauser, P.I.) and a subcontract of that award (R.M. Howell, P.I). No conflicts of interest to disclose.

Dosimetric Comparison of Combined Intensity-Modulated Radiotherapy (IMRT) and Proton Therapy Versus IMRT Alone for Pelvic and Para-Aortic Radiotherapy in Gynecologic Malignancies

To perform a dosimetric comparison of intensity-modulated radiotherapy (IMRT), passive scattering proton therapy (PSPT), and intensity-modulated proton therapy (IMPT) to the para-aortic (PA) nodal region in women with locally advanced gynecologic malignancies. The CT treatment planning scans of 10 consecutive patients treated with IMRT to the pelvis and PA nodes were identified. The clinical target volume was defined by the primary tumor for patients with cervical cancer and by the vagina and paravaginal tissues for patients with endometrial cancer, in addition to the regional lymph nodes. The IMRT, PSPT, and IMPT plans were generated using the Eclipse Treatment Planning System and were analyzed for various dosimetric endpoints. Two groups of treatment plans including proton radiotherapy were created: IMRT to pelvic nodes with PSPT to PA nodes (PSPT/IMRT), and IMRT to pelvic nodes with IMPT to PA nodes (IMPT/IMRT). The IMRT and proton RT plans were optimized to deliver 50.4 Gy or Gy (relative biologic effectiveness [RBE)), respectively. Dose-volume histograms were analyzed for all of the organs at risk. The paired t test was used for all statistical comparison. The small-bowel V(20), V(30), V(35), andV(40) were reduced in PSPT/IMRT by 11%, 18%, 27%, and 43%, respectively (p < 0.01). Treatment with IMPT/IMRT demonstrated a 32% decrease in the small-bowel V(20). Treatment with PSPT/IMRT showed statistically significant reductions in the body V(5-20); IMPT/IMRT showed reductions in the body V(5-15). The dose received by half of both kidneys was reduced by PSPT/IMRT and by IMPT/IMRT. All plans maintained excellent coverage of the planning target volume. Compared with IMRT alone, PSPT/IMRT and IMPT/IMRT had a statistically significant decrease in dose to the small and large bowel and kidneys, while maintaining excellent planning target volume coverage. Further studies should be done to correlate the clinical significance of these findings.

SU-E-T-507: Respiratory Motion Management for Early Stage Lung Tumors: Is the Advantage Greater for Protons or Photons?

Purpose: To test the validity of the assumption that passive scatteringproton therapy (PSPT) would benefit more from respiratory motion management techniques of deep‐inspiration breath hold (DIBH) and end‐exhale respiratory gating compared to 3D conformal photonradiotherapy (3DCRT) for early stage lungtumors. Methods: Four‐dimensional and breath‐hold CT scans were acquired for patients with target motion greater than 10mm. Motion‐encompassing (standard) plans were created using target volume contoured on the 4D 10‐phase maximum intensity projection image and 10‐ phase average CT for dose calculations. Respiratory gating was simulated by creating average CT for three exhale phases (T40, 50, 60) for contouring and dose calculation. DIBH plans were simulated from breath‐hold CT scans for contouring and dose calculation. PSPT and 3DCRT plan triplets (standard, gated, BH) were designed by trained dosimetrists using consistent margins and current clinical standards. Plans were normalized to equal target dose coverage in PSPT and 3DCRT. For each patient, mean lungdose (MLD) and V20 of gated and DIBH plans were compared to standard plan. Results: For 3 patients, PSPT gating reduced MLD ranging 6–14% and V20 6–16%. 3DCRT gating reduced MLD ranging 8–19% and V20 7–19%. 3DCRT DIBH reduced MLD between 18–37% and V20 21–38%, while PSPT DIBH plans reduced MLD between 8–33% and V20 8–23%. Conclusions: This planning study showed that 3DCRT showed a larger reduction in MLD and V20 as compared to PSPT in both gating and DIBH. Furthermore, DIBH provided an equal or larger reduction than gating in both modalities. MLD and V20 are inherently lower in PSPT than 3DCRT, but DIBH and gating lead to larger benefits in 3DCRT. One reason that 3DCRT may benefit more than PSPT is due to reduced field sizes sparing tissue throughout the patient in 3DCRT as opposed to savings only throughout the proton beam range in PSPT.

Proton Stereotactic Body Radiation Therapy for Clinically Challenging Cases of Centrally and Superiorly Located Stage I Non-Small-Cell Lung Cancer

To minimize toxicity while maintaining tumor coverage with stereotactic body radiation therapy (SBRT) for centrally or superiorly located stage I non-small-cell lung cancer (NSCLC), we investigated passive-scattering proton therapy (PSPT) and intensity-modulated proton therapy (IMPT). Fifteen patients with centrally or superiorly located (within 2 cm of critical structures) stage I NSCLC were treated clinically with three-dimensional photon SBRT (50 Gy in 4 fractions). The photon SBRT plan was compared with the PSPT and IMPT plans. The maximum tolerated dose (MTD) was defined as the dose that exceeded the dose--volume constraints in the critical structures. Only 6 photon plans satisfied the >95% planning target volume (PTV) coverage and MTD constraints, compared to 12 PSPT plans (p = 0.009) and 14 IMPT plans (p = 0.001). Compared with the photon SBRT plans, the PSPT and IMPT plans significantly reduced the mean total lung dose from 5.4 Gy to 3.5 Gy (p < 0.001) and 2.8 Gy (p < 0.001) and reduced the total lung volume receiving 5 Gy, 10 Gy, and 20 Gy (p < 0.001). When the PTV was within 2 cm of the critical structures, the PSPT and IMPT plans significantly reduced the mean maximal dose to the aorta, brachial plexus, heart, pulmonary vessels, and spinal cord. For centrally or superiorly located stage I NSCLC, proton therapy, particularly IMPT, delivered ablative doses to the target volume and significantly reduced doses to the surrounding normal tissues compared with photon SBRT.