Proton FLASH Research Articles

Very high-energy electron therapy as light-particle alternative to transmission proton FLASH therapy – An evaluation of dosimetric performances

PurposeClinical translation of FLASH-radiotherapy (RT) to deep-seated tumours is still a technological challenge. One proposed solution consists of using ultra-high dose rate transmission proton (TP) beams of about 200–250 MeV to irradiate the tumour with the flat entrance of the proton depth-dose profile. This work evaluates the dosimetric performance of very high-energy electron (VHEE)-based RT (50–250 MeV) as a potential alternative to TP-based RT for the clinical transfer of the FLASH effect. MethodsBasic physics characteristics of VHEE and TP beams were compared utilizing Monte Carlo simulations in water. A VHEE-enabled research treatment planning system was used to evaluate the plan quality achievable with VHEE beams of different energies, compared to 250 MeV TP beams for a glioblastoma, an oesophagus, and a prostate cancer case. ResultsLike TP, VHEE above 100 MeV can treat targets with roughly flat (within ± 20 %) depth-dose distributions. The achievable dosimetric target conformity and adjacent organs-at-risk (OAR) sparing is consequently driven for both modalities by their lateral beam penumbrae. Electron beams of 400[500] MeV match the penumbra of 200[250] MeV TP beams and penumbra is increased for lower electron energies. For the investigated patient cases, VHEE plans with energies of 150 MeV and above achieved a dosimetric plan quality comparable to that of 250 MeV TP plans. For the glioblastoma and the oesophagus case, although having a decreased conformity, even 100 MeV VHEE plans provided a similar target coverage and OAR sparing compared to TP. ConclusionsVHEE-based FLASH-RT using sufficiently high beam energies may provide a lighter-particle alternative to TP-based FLASH-RT with comparable dosimetric plan quality.

Streamlined pin-ridge-filter design for single-energy proton FLASH planning.

FLASH radiotherapy (FLASH-RT) with ultra-high dose rate has yielded promising results in reducing normal tissue toxicity while maintaining tumor control. Planning with single-energy proton beams modulated by ridge filters (RFs) has been demonstrated feasible for FLASH-RT. This study explored the feasibility of a streamlined pin-shaped RF (pin-RF) design, characterized by coarse resolution and sparsely distributed ridge pins, for single-energy proton FLASH planning. An inverse planning framework integrated within a treatment planning system was established to design streamlined pin RFs for single-energy FLASH planning. The framework involves generating a multi-energy proton beam plan using intensity-modulated proton therapy (IMPT) planning based on downstream energy modulation strategy (IMPT-DS), followed by a nested pencil-beam-direction-based (PBD-based) spot reduction process to iteratively reduce the total number of PBDs and energy layers along each PBD for the IMPT-DS plan. The IMPT-DS plan is then translated into the pin-RFs and the single-energy beam configurations for IMPT planning with pin-RFs (IMPT-RF). This framework was validated on three lung cases, quantifying the FLASH dose of the IMPT-RF plan using the FLASH effectiveness model. The FLASH dose was then compared to the reference dose of a conventional IMPT plan to measure the clinical benefit of the FLASH planning technique. The IMPT-RF plans closely matched the corresponding IMPT-DS plans in high dose conformity (conformity index of <1.2), with minimal changes in V7Gy and V7.4Gy for the lung (<3%) and small increases in maximum doses (Dmax) for other normal structures (<3.4Gy). Comparing the FLASH doses to the doses of corresponding IMPT-RF plans, drastic reductions of up to nearly 33% were observed in Dmax for the normal structures situated in the high-to-moderate-dose regions, while negligible changes were found in Dmax for normal structures in low-dose regions. Positive clinical benefits were seen in comparing the FLASH doses to the reference doses, with notable reductions of 21.4%-33.0% in Dmax for healthy tissues in the high-dose regions. However, in the moderate-to-low-dose regions, only marginal positive or even negative clinical benefit for normal tissues were observed, such as increased lung V7Gy and V7.4Gy (up to 17.6%). A streamlined pin-RF design was developed and its effectiveness for single-energy proton FLASH planning was validated, revealing positive clinical benefits for the normal tissues in the high dose regions. The coarsened design of the pin-RF demonstrates potential advantages, including cost efficiency and ease of adjustability, making it a promising option for efficient production.

FLASH radiotherapy sparing effect on the circulating lymphocytes in pencil beam scanning proton therapy: impact of hypofractionation and dose rate

Purpose. The sparing effect of ultra-high dose rate (FLASH) radiotherapy has been reported, but its potential to mitigate depletion of circulating blood and lymphocytes (CL) has not been investigated in pencil-beam scanning-based (PBS) proton therapy, which could potentially reduce the risk of radiation-induced lymphopenia. Material and methods. A time-dependent framework was used to score the dose to the CL during the course of radiotherapy. For brain patients, cerebral vasculatures were semi-automatic segmented from 3T MR-angiography data. A dynamic beam delivery system was developed capable of simulating spatially varying instantaneous dose rates of PBS treatment plans, and which is based on realistic beam delivery parameters that are available clinically. We simulated single and different hypofractionated PBS intensity modulated proton therapy (IMPT) FLASH schemes using 600 nA beam current along with conventionally fractionated IMPT treatment plan at 2 nA beam current. The dosimetric impact of treatment schemes on CL was quantified, and we also evaluated the depletion in subsets of CL based on their radiosensitivity. Results. The proton FLASH sparing effect on CL was observed. In single-fraction PBS FLASH, just 1.5% of peripheral blood was irradiated, whereas hypofractionated FLASH irradiated 7.3% of peripheral blood. In contrast, conventional fractionated IMPT exposed 42.4% of peripheral blood to radiation. PBS FLASH reduced the depletion rate of CL by 69.2% when compared to conventional fractionated IMPT. Conclusion. Our dosimetric blood flow model provides quantitative measures of the PBS FLASH sparing effect on the CL in radiotherapy for brain cancer. FLASH Single treatment fraction offers superior CL sparing when compared to hypofractionated FLASH and conventional IMPT, supporting assumptions about reducing risks of lymphopenia compared to proton therapy at conventional dose rates. The results also indicate that faster conformal FLASH delivery, such as passive patient-specific energy modulation, may further enhance the sparing of the immune system.

Feasibility study of multiple-energy Bragg peak proton FLASH on a superconducting gantry with large momentum acceptance.

While the Bragg peak proton beam (BP) is capable of superior target conformity and organs-at-risk sparing than the transmission proton beam (TB), its efficacy in FLASH-RT is hindered by both a slow energy switching process and the beam current. A universal range shifter (URS) can pull back the high-energy proton beam while preserving the beam current. Meanwhile, a superconducting gantry with large momentum acceptance (LMA-SC gantry) enables fast energy switching. This study explores the feasibility of multiple-energy BP FLASH-RT on the LMA-SC gantry. A simultaneous dose and spot map optimization algorithm was developed for BP FLASH-RT treatment planning to improve the dose delivery efficiency. The URS was designed to be 0-27cm thick, with 1cm per step. BP plans using the URS were optimized using single-field optimization (SFO) and multiple-field optimization (MFO) for ten prostate cancer patients and ten lung cancer patients. The plan delivery parameters, dose, and dose rate metrics of BP plans were compared to those of TB plans using the parameters of the LMA-SC gantry. Compared to TB plans, BP plans significantly reduced MUs by 42.7% (P<0.001) with SFO and 33.3% (P<0.001) with MFO for prostate cases. For lung cases, the reduction in MUs was 56.8% (P<0.001) with SFO and 36.4% (P<0.001) with MFO. BP plans also outperformed TB plans by reducing mean normal tissue doses. BP-SFO plans achieved a reduction of 56.7% (P<0.001) for prostate cases and 57.7% (P<0.001) for lung cases, while BP-MFO plans achieved a reduction of 54.2% (P<0.001) for the prostate case and 40.0% (P<0.001) for lung cases. For both TB and BP plans, normal tissues in prostate and lung cases received 100.0% FLASH dose rate coverage(>40Gy/s). By utilizing the URS and the LMA-SC gantry, it is possible to perform multiple-energy BP FLASH-RT, resulting in better normal tissue sparing, as compared to TB plans.

Design of synchrotron for proton FLASH radiotherapy

Proton FLASH, which combines the advantages of a better spatial dose distribution of protons with the unique temporal effect of FLASH radiotherapy, is currently a hot topic of international research. In this study, a series of innovative methods are proposed to manipulate the beam with the longitudinal dynamics and to extract particles from the synchrotron, thus meeting the dose rate requirements for proton FLASH point scanning radiotherapy in a 1L volume in the target area.

Proton FLASH Irradiation Platform for Small Animal Setup at Chang Gung Memorial Hospital

Proton FLASH Irradiation Platform for Small Animal Setup at Chang Gung Memorial Hospital

Proton FLASH irradiation setup for preclinical studies at HZB

The HZB cyclotron continues to provide protons for eye-tumor treatment in collaboration with the Charité – Universitätsmedizin Berlin after 24 years and more than 4400 patients so far. With the perspective of broadening its research capabilities in the field of radiation therapy, intensive effort has been dedicated towards proton FLASH irradiation, which requires ultra-high dose rates or beam intensities.By combining a fast and reliable switch-off mechanism, accurate dosimetry, and a double-scattering beam nozzle with a static 3D-printed range modulator, HZB is now able to deliver a dose rate above 150 Gy/s within a flat circular irradiation field of 18mm diameter and a 27mm spread-out Bragg peak with a distal fall-off of 1mm in water. The reproducibility of the delivered dose meets the clinical acceptance criteria for a total irradiation time as low as 2.5 ms.The first experiments with this setup were used on fibroblastic and sarcoma organoids. By adapting the design to a 35mm lateral field and using optimal accelerator tuning to increase beam transmission, similar or even higher dose rates are expected, satisfying thus the FLASH conditions for eye-tumor treatment with protons.

A Novel Inverse Algorithm To Solve the Integrated Optimization of Dose, Dose Rate, and Linear Energy Transfer of Proton FLASH Therapy With Sparse Filters

Purpose:The recently proposed Integrated Physical Optimization Intensity Modulated Proton Therapy (IPO-IMPT) framework allows simultaneous optimization of dose, dose rate, and linear energy transfer (LET) for FLASH treatment planning. Finding solutions to IPO-IMPT is difficult due to computational intensiveness. Nevertheless, an inverse solution that simultaneously specifies the geometry of a sparse filter and weights of a proton intensity map is desirable for both clinical and preclinical applications. Such solutions can reduce effective biological dose to organs at risk in cancer patients as well as reduce the number of animal irradiations needed to derive extra biological dose models in preclinical studies. Methods:Unlike the initial forward heuristic, this inverse IPO-IMPT solution includes simultaneous optimization of sparse range compensation, sparse range modulation, and spot intensity. The daunting computational tasks vital to this endeavor were resolved iteratively with a distributed computing framework to enable Simultaneous Intensity and Energy Modulation and Compensation (SIEMAC). SIEMAC was demonstrated on a human central lung cancer patient and a minipig. Results:SIEMAC simultaneously improves maps of spot intensities and patient-field-specific sparse range compensators and range modulators. For the lung cancer patient, at our maximum nozzle current of 300 nA, dose rate coverage above 100 Gy/s increased from 57% to 96% in the lung and from 93% to 100% in the heart, and LET coverage above 4 keV/μm dropped from 68% to 9% in the lung and from 26% to <1% in the heart. For a simple minipig plan, the full-width-half-maximum of the dose, dose rate, and LET distributions decreased by 30%, 1.6%, and 57%, respectively, again with similar target dose coverage, thus reducing uncertainty in these quantities for preclinical studies. Conclusion:The inverse solution to IPO-IMPT demonstrated the capability to simultaneously modulate sub-spot proton energy and intensity distributions for clinical and preclinical studies.

Shoot-through proton FLASH irradiation lowers linear energy transfer in organs at risk for neurological tumors and is robust against density variations

Objective. The goal of the study was to test the hypothesis that shoot-through FLASH proton beams would lead to lower dose-averaged LET (LETD) values in critical organs, while providing at least equal normal tissue sparing as clinical proton therapy plans. Approach. For five neurological tumor patients, pencil beam scanning (PBS) shoot-through plans were made, using the maximum energy of 227 MeV and assuming a hypothetical FLASH protective factor (FPF) of 1.5. The effect of different FPF ranging from 1.2 to 1.8 on the clinical goals were also considered. LETD was calculated for the clinical plan and the shoot-through plan, applying a 2 Gy total dose threshold (RayStation 8 A/9B and 9A-IonRPG). Robust evaluation was performed considering density uncertainty (±3% throughout entire volume). Main results. Clinical plans showed large LETD variations compared to shoot-through plans and the maximum LETD in OAR is 1.2–8 times lower for the latter. Although less conformal, shoot-through plans met the same clinical goals as the clinical plans, for FLASH protection factors above 1.4. The FLASH shoot-through plans were more robust to density uncertainties with a maximum OAR D2% increase of 0.6 Gy versus 5.7 Gy in the clinical plans. Significance. Shoot-through proton FLASH beams avoid uncertainties in LETD distributions and proton range, provide adequate target coverage, meet planning constraints and are robust to density variations.

Dosimetric and biologic intercomparison between electron and proton FLASH beams

Background and purposeThe FLASH effect has been validated in different preclinical experiments with electrons (eFLASH) and protons (pFLASH) operating at an average dose rate above 40 Gy/s. However, no systematic intercomparison of the FLASH effect produced by eFLASHvs. pFLASH has yet been performed and constitutes the aim of the present study. Materials and methodsThe electron eRT6/Oriatron/CHUV/5.5 MeV and proton Gantry1/PSI/170 MeV were used to deliver conventional (0.1 Gy/s eCONV and pCONV) and FLASH (≥110 Gy/s eFLASH and pFLASH) dose rates. Protons were delivered in transmission. Dosimetric and biologic intercomparisons were performed using previously validated dosimetric approaches and experimental murine models. ResultsThe difference between the average absorbed dose measured at Gantry 1 with PSI reference dosimeters and with CHUV/IRA dosimeters was −1.9 % (0.1 Gy/s) and + 2.5 % (110 Gy/s). The neurocognitive capacity of eFLASH and pFLASH irradiated mice was indistinguishable from the control, while both eCONV and pCONV irradiated cohorts showed cognitive decrements. Complete tumor response was obtained after an ablative dose of 20 Gy delivered with the two beams at CONV and FLASH dose rates. Tumor rejection upon rechallenge indicates that anti-tumor immunity was activated independently of the beam-type and the dose-rate. ConclusionDespite major differences in the temporal microstructure of proton and electron beams, this study shows that dosimetric standards can be established. Normal brain protection and tumor control were produced by the two beams. More specifically, normal brain protection was achieved when a single dose of 10 Gy was delivered in 90 ms or less, suggesting that the most important physical parameter driving the FLASH sparing effect might be the mean dose rate. In addition, a systemic anti-tumor immunological memory response was observed in mice exposed to high ablative dose of electron and proton delivered at CONV and FLASH dose rate.

Proton Single-Energy Bragg-Peak FLASH Using Clinical Systems Can Achieve IMPT-Equivalent Plan Quality for Breast and Prostate Cancers

Most current proton FLASH-RT studies focus on transmission proton techniques. In this study, we propose a novel method for achieving FLASH dose rate in hypofractionated proton radiotherapy using the Bragg peak of a single-energy proton beam. The dosimetric characteristics using this novel technique for proton pencil beam scanning (PBS) stereotactic body radiation therapy (SBRT) of prostate and breast cancers were first investigated based on the clinically available cyclotron beam parameters. This novel approach uses the distal tracking technique that enables PBS Bragg-peak of the highest proton energy to adapt to the target distally. Positioning of the Bragg peak at different depths is achieved using a universal range shifter and range compensator. To investigate the feasibility of this approach, we developed an in-house treatment planning platform for intensity-modulated proton therapy (IMPT) delivery and performed dosimetric studies on prostate and breast SBRT cases previously treated with conventional proton PBS technique. FLASH plans were generated using a similar clinical beam arrangement to deliver 40 Gy (RBE) in 5 fractions. Dose metrics were compared between the clinical and FLASH plans. Dose-rate volume histograms (DRVH) were also calculated to investigate the 40 Gy/s coverage (V40 Gy/s) of organs-at-risk (OARs) for FLASH plans. The distal tracking can precisely stop the Bragg peak at the target distal edge, and Bragg peak plans achieved tumor coverage and dose conformality equivalent to IMPT plans. The clinical IMPT plans yielded slightly superior target dose uniformity -CTV Dmax of FLASH plans was 10% higher for prostate and 2% higher for breast. There was no significant difference between the clinical and FLASH plans in dose metrics for major OARs, including rectum, large bowel, heart, and lung. Higher maximal doses to femoral heads (∼2 Gy) and urethra (∼6 Gy) were observed in prostate FLASH plans than in the clinical plans but were still within clinically accepted dose limits. The V40 Gy/s for OARs were >90% for prostate FLASH plans and >76.5% for breast FLASH plans. The proposed single-energy Bragg-peak FLASH technique eliminates exit dose associated with transmission proton FLASH and can still yield comparable plan quality and OAR sparing while preserve sufficient FLASH dose rate coverage for prostate and breast proton SBRT. This study demonstrates the potential application of Bragg peaks for highly conformal FLASH-RT using clinical cyclotron systems to treat prostate and breast cancer patients, which moves towards clinical application.

Luminescence imaging of water irradiated by protons under FLASH radiation therapy conditions

Objective. FLASH radiation therapy with ultrahigh dose rates (UHDR) has the potential to reduce damage to normal tissue while maintaining anti-tumor efficacy. However, rapid and precise dose distribution measurements remain difficult for FLASH radiation therapy with proton beams. To solve this problem, we performed luminescence imaging of water following irradiation by a UHDR proton beam captured using a charge-coupled device camera. Approach. We used 60 MeV proton beams with dose rates of 0.03–837 Gy s−1 from a cyclotron. Therapeutic 139.3 MeV proton beams with dose rates of 0.45–4320 Gy s−1 delivered by a synchrotron-based proton therapy system were also tested. The luminescent light intensity induced by the UHDR beams was compared with that produced by conventional beams to compare the dose rate dependency of the light intensity and its profile. Main results. Luminescence images of water were clearly visualized under UHDR conditions, with significantly shorter exposure times than those with conventional beams. The light intensity was linearly proportional to the delivered dose, which is similar to that of conventional beams. No significant dose-rate dependency was observed for 0.03–837 Gy s−1. The light-intensity profiles of the UHDR beams agreed with those of conventional beams. The results did not differ between accelerators (synchrotron or cyclotron) and beam energies. Significance. Luminescence imaging of water is achievable with UHDR proton beams as well as with conventional beams. The proposed method should be suitable for rapid and easy quality assurance investigations for proton FLASH therapy, because it facilitates real-time, filmless measurements of dose distributions, and is useful for rapid feedback.

Modeling ultra-high dose rate electron and proton FLASH effect with the physicochemical approach

Objective. A physicochemical model built on the radiochemical kinetic theory was recently proposed in (Labarbe et al ) to explain the FLASH effect. We performed extensive simulations to scrutinize its applicability for oxygen depletion studies and FLASH-related experiments involving both proton and electron beams. Approach. Using the dose and beam delivery parameters for each FLASH experiment, we numerically solved the radiochemical rate equations comprised of a set of coupled nonlinear ordinary differential equations to obtain the area under the curve (AUC) of radical concentrations. Main results. The modeled differences in AUC induced by ultra-high dose rates appeared to correlate well with the FLASH effect. (i) For the whole brain irradiation of mice performed in (Montay-Gruel et al ), the threshold dose rate values for memory preservation coincided with those at which AUC started to decrease much less rapidly. (ii) For the proton pencil beam scanning FLASH of (Cunningham et al ), we found linear correlations between radicals’ AUC and the biological endpoints: TGF-β1, leg contracture and plasma level of cytokine IL-6. (iii) Compatible with the findings of the proton FLASH experiment in (Kim et al ), we found that radicals’ AUC at the entrance and mid-Spread-Out Bragg peak regions were highly similar. In addition, our model also predicted ratios of oxygen depletion G-values between normal and UHDR irradiation similar to those observed in (Cao et al ) and (El Khatib et al ). Significance. Collectively, our results suggest that the normal tissue sparing conferred by UHDR irradiation may be due to the lower degree of exposure to peroxyl and superoxide radicals. We also found that the differential effect of dose rate on the radicals’ AUC was less pronounced at lower initial oxygen levels, a trait that appears to align with the FLASH differential effect on normal versus tumor tissues.

Passive SOBP generation from a static proton pencil beam using 3D-printed range modulators for FLASH experiments

The University Proton Therapy facility in Dresden (UPTD), Germany, is equipped with an experimental room with a beamline providing a static pencil beam. High proton beam currents can be achieved at this beamline which makes it suitable for FLASH experiments. However, the established experimental setup uses only the entrance channel of the proton Bragg curve. In this work, a set of 3D-printed range modulators designed to generate spread out Bragg peaks (SOBPs) for radiobiological experiments at ultra-high dose rate at this beamline is described. A new method to optimize range modulators specifically for the case of a static pencil beam based on the central depth dose profile is introduced. Modulators for two different irradiation setups were produced and characterized experimentally by measurements of lateral and depth dose distributions using different detectors. In addition, Monte Carlo simulations were performed to assess profiles of the dose averaged linear energy transfer (LETD) in water. These newly produced range modulators will allow future proton FLASH experiments in the SOBP at UPTD with two different experimental setups.

Considerations and current status of treatment planning for proton FLASH radiotherapy

Considerations and current status of treatment planning for proton FLASH radiotherapy

Implementation of novel measurement-based patient-specific QA for pencil beam scanning proton FLASH radiotherapy.

Several studies have shown pencil beam scanning (PBS) proton therapy is a feasible and safe modality to deliver conformal and ultra-high dose rate (UHDR) FLASH radiation therapy. However, it would be challenging and burdensome to conduct the quality assurance (QA) of the dose rate along with conventional patient-specific QA (psQA). To demonstrate a novel measurement-based psQA program for UHDR PBS proton transmission FLASH radiotherapy (FLASH-RT) using a high spatiotemporal resolution 2D strip ionization chamber array (SICA). The SICA is a newly designed open-air strip-segmented parallel plate ionization chamber, which is capable of measuring spot position and profile through 2mm-spacing-strip electrodes at a 20kHz sampling rate (50μs per event) and has been characterized to exhibit excellent dose and dose rate linearity under UHDR conditions. A SICA-based delivery log was collected for each irradiation containing the measured position, size, dwell time, and delivered MU for each planned spot. Such spot-level information was compared with the corresponding quantities in the treatment planning system (TPS). The dose and dose rate distributions were reconstructed on patient CT using the measured SICA log and compared to the planned values in volume histograms and 3D gamma analysis. Furthermore, the 2D dose and dose rate measurements were compared with the TPS calculations of the same depth. In addition, simulations using different machine-delivery uncertainties were performed, and QA tolerances were deduced. A transmission proton plan of 250MeV for a lung lesion was planned and measured in a dedicated ProBeam research beamline (Varian Medical System) with a nozzle beam current between 100 to 215nA. The worst gamma passing rates for dose and dose rate of the 2D SICA measurements (four fields) compared to TPS prediction (3%/3mm criterion) were 96.6% and 98.8%, respectively, whereas the SICA-log reconstructed 3D dose distribution achieved a gamma passing rate of 99.1% (2%/2mm criterion) compared to TPS. The deviations between SICA measured log, and TPS were within 0.3ms for spot dwell time with a mean difference of 0.069±0.11 s, within 0.2mm for spot position with a mean difference of -0.016±0.03mm in the x-direction, and -0.036±0.059mm in the y-direction, and within 3% for delivered spot MUs. Volume histogram metric of dose (D95) and dose rate (V40Gy/s ) showed minimal differences, within less than 1%. This work is the first to describe and validate an all-in-one measurement-based psQA framework that can fulfill the goals of validating the dose rate accuracy in addition to dosimetric accuracy for proton PBS transmission FLASH-RT. The successful implementation of this novel QA program can provide future clinical practice with more confidence in the FLASH application.

OC-0595 Proton FLASH: Impact of beam pauses on the biological response in an acute damage mouse model

OC-0595 Proton FLASH: Impact of beam pauses on the biological response in an acute damage mouse model

MO-0720 Proton FLASH: Impact of dose rate on biological response in an acute damage mouse model

MO-0720 Proton FLASH: Impact of dose rate on biological response in an acute damage mouse model

Absence of Tissue-Sparing Effects in Partial Proton FLASH Irradiation in Murine Intestine.

Ultra-high dose rate irradiation has been reported to protect normal tissues more than conventional dose rate irradiation. This tissue sparing has been termed the FLASH effect. We investigated the FLASH effect of proton irradiation on the intestine as well as the hypothesis that lymphocyte depletion is a cause of the FLASH effect. A 16 × 12 mm2 elliptical field with a dose rate of ~120 Gy/s was provided by a 228 MeV proton pencil beam. Partial abdominal irradiation was delivered to C57BL/6j and immunodeficient Rag1-/-/C57 mice. Proliferating crypt cells were counted at 2 days post exposure, and the thickness of the muscularis externa was measured at 280 days following irradiation. FLASH irradiation did not reduce the morbidity or mortality of conventional irradiation in either strain of mice; in fact, a tendency for worse survival in FLASH-irradiated mice was observed. There were no significant differences in lymphocyte numbers between FLASH and conventional-dose-rate mice. A similar number of proliferating crypt cells and a similar thickness of the muscularis externa following FLASH and conventional dose rate irradiation were observed. Partial abdominal FLASH proton irradiation at 120 Gy/s did not spare normal intestinal tissue, and no difference in lymphocyte depletion was observed. This study suggests that the effect of FLASH irradiation may depend on multiple factors, and in some cases dose rates of over 100 Gy/s do not induce a FLASH effect and can even result in worse outcomes.

Feasibility study of hybrid inverse planning with transmission beams and single-energy spread-out Bragg peaks for proton FLASH radiotherapy.

Ultra-high dose rate (FLASH) proton planning with only transmission beams (TBs) has limitations in normal tissue sparing. The single-energy spread-out Bragg peaks (SESOBPs) of the FLASH dose rate have been demonstrated feasible for proton FLASH planning. To investigate the feasibility of combining TBs and SESOBPs for proton FLASH treatment. A hybrid inverse optimization method was developed to combine the TBs and SESOBPs (TB-SESOBP) for FLASH planning. The SESOBPs were generated field-by-field from spreading out the BPs by pre-designed general bar ridge filters (RFs) and placed at the central target by range shifters (RSs) to obtain a uniform dose within the target. The SESOBPs and TBs were fully placed field-by-field allowing automatic spot selection and weighting in the optimization process. A spot reduction strategy was conducted in the optimization process to push up the minimum MU/spot assuring the plan deliverability at beam current of 165 nA. The TB-SESOBP plans were validated in comparison with the TB only (TB-only) plans and the plans with the combination of TBs and BPs (TB-BP plans) regarding 3D dose and dose rate (dose-averaged dose rate) distributions for five lung cases. The FLASH dose rate coverage (V40Gy/s ) was evaluated in the structure volume receiving>10% of the prescription dose. Compared to the TB-only plans, the mean spinal cord D1.2cc drastically reduced by 41% (P<0.05), the mean lung V7Gy and V7.4Gy moderately reduced by up to 17% (P<0.05), and the target dose homogeneity slightly increased in the TB-SESOBP plans. Comparable dose homogeneity was achieved in both TB-SESOBP and TB-BP plans. Besides, prominent improvements were achieved in lung sparing for the cases of relatively large targets by the TB-SESOBP plans compared to the TB-BP plans. The targets and the skin were fully covered with the FLASH dose rate in all three plans. For the OARs, V40Gy/s =100% was achieved by the TB-only plans while V40Gy/s >85% was obtained by the other two plans. We have demonstrated that the hybrid TB-SESOBP planning was feasible to achieve FLASH dose rate for proton therapy. With pre-designed general bar RFs, the hybrid TB-SESOBP planning could be implemented for proton adaptive FLASH radiotherapy. As an alternative FLASH planning approach to TB-only planning, the hybrid TB-SESOBP planning has great potential in dosimetrically improving OAR sparing while maintaining high target dose homogeneity.