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Title: Pencil beam scanning proton therapy vs rotational arc radiation therapy: A treatment planning comparison for postoperative oropharyngeal cancer

Abstract

Patients diagnosed with head and neck cancer are traditionally treated with photon radiotherapy. Proton therapy is currently being used clinically and may potentially reduce treatment-related toxicities by minimizing the dose to normal organs in the treatment of postoperative oropharyngeal cancer. The finite range of protons has the potential to significantly reduce normal tissue toxicity compared to photon radiotherapy. Seven patients were planned with both proton and photon modalities. The planning goal for both modalities was achieving the prescribed dose to 95% of the planning target volume (PTV). Dose-volume histograms were compared in which all cases met the target coverage goals. Mean doses were significantly lower in the proton plans for the oral cavity (1771 cGy photon vs 293 cGy proton, p < 0.001), contralateral parotid (1796 cGy photon vs 1358 proton, p < 0.001), and the contralateral submandibular gland (3608 cGy photon vs 3251 cGy proton, p = 0.03). Average total integral dose was 9.1% lower in proton plans. The significant dosimetric sparing seen with proton therapy may lead to reduced side effects such as pain, weight loss, taste changes, and dry mouth. Prospective comparisons of protons vs photons for disease control, toxicity, and patient-reported outcomes are therefore warranted andmore » currently being pursued.« less

Authors:
; ; ; ; ;
Publication Date:
OSTI Identifier:
22685174
Resource Type:
Journal Article
Resource Relation:
Journal Name: Medical Dosimetry; Journal Volume: 42; Journal Issue: 1; Other Information: Copyright (c) 2017 Elsevier Science B.V., Amsterdam, The Netherlands, All rights reserved.; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
61 RADIATION PROTECTION AND DOSIMETRY; 62 RADIOLOGY AND NUCLEAR MEDICINE; ANIMAL TISSUES; COMPARATIVE EVALUATIONS; DIAGNOSIS; GLANDS; HEAD; INTEGRAL DOSES; NECK; NEOPLASMS; ORAL CAVITY; PATIENTS; PHOTONS; PLANNING; PROTON BEAMS; RADIOTHERAPY; SIDE EFFECTS; TOXICITY

Citation Formats

Apinorasethkul, Ontida, E-mail: Ontida.a@gmail.com, Kirk, Maura, Teo, Kevin, Swisher-McClure, Samuel, Lukens, John N., and Lin, Alexander. Pencil beam scanning proton therapy vs rotational arc radiation therapy: A treatment planning comparison for postoperative oropharyngeal cancer. United States: N. p., 2017. Web. doi:10.1016/J.MEDDOS.2016.09.004.
Apinorasethkul, Ontida, E-mail: Ontida.a@gmail.com, Kirk, Maura, Teo, Kevin, Swisher-McClure, Samuel, Lukens, John N., & Lin, Alexander. Pencil beam scanning proton therapy vs rotational arc radiation therapy: A treatment planning comparison for postoperative oropharyngeal cancer. United States. doi:10.1016/J.MEDDOS.2016.09.004.
Apinorasethkul, Ontida, E-mail: Ontida.a@gmail.com, Kirk, Maura, Teo, Kevin, Swisher-McClure, Samuel, Lukens, John N., and Lin, Alexander. Sat . "Pencil beam scanning proton therapy vs rotational arc radiation therapy: A treatment planning comparison for postoperative oropharyngeal cancer". United States. doi:10.1016/J.MEDDOS.2016.09.004.
@article{osti_22685174,
title = {Pencil beam scanning proton therapy vs rotational arc radiation therapy: A treatment planning comparison for postoperative oropharyngeal cancer},
author = {Apinorasethkul, Ontida, E-mail: Ontida.a@gmail.com and Kirk, Maura and Teo, Kevin and Swisher-McClure, Samuel and Lukens, John N. and Lin, Alexander},
abstractNote = {Patients diagnosed with head and neck cancer are traditionally treated with photon radiotherapy. Proton therapy is currently being used clinically and may potentially reduce treatment-related toxicities by minimizing the dose to normal organs in the treatment of postoperative oropharyngeal cancer. The finite range of protons has the potential to significantly reduce normal tissue toxicity compared to photon radiotherapy. Seven patients were planned with both proton and photon modalities. The planning goal for both modalities was achieving the prescribed dose to 95% of the planning target volume (PTV). Dose-volume histograms were compared in which all cases met the target coverage goals. Mean doses were significantly lower in the proton plans for the oral cavity (1771 cGy photon vs 293 cGy proton, p < 0.001), contralateral parotid (1796 cGy photon vs 1358 proton, p < 0.001), and the contralateral submandibular gland (3608 cGy photon vs 3251 cGy proton, p = 0.03). Average total integral dose was 9.1% lower in proton plans. The significant dosimetric sparing seen with proton therapy may lead to reduced side effects such as pain, weight loss, taste changes, and dry mouth. Prospective comparisons of protons vs photons for disease control, toxicity, and patient-reported outcomes are therefore warranted and currently being pursued.},
doi = {10.1016/J.MEDDOS.2016.09.004},
journal = {Medical Dosimetry},
number = 1,
volume = 42,
place = {United States},
year = {Sat Apr 01 00:00:00 EDT 2017},
month = {Sat Apr 01 00:00:00 EDT 2017}
}
  • Purpose: To investigate, in a treatment plan design and robustness study, whether proton pencil beam scanning (PBS) has the potential to offer advantages, relative to interfraction uncertainties, over photon volumetric modulated arc therapy (VMAT) in a locally advanced rectal cancer patient population. Methods and Materials: Ten patients received a planning CT scan, followed by an average of 4 weekly offline CT verification CT scans, which were rigidly co-registered to the planning CT. Clinical PBS plans were generated on the planning CT, using a single-field uniform-dose technique with single-posterior and parallel-opposed (LAT) fields geometries. The VMAT plans were generated on the planningmore » CT using 2 6-MV, 220° coplanar arcs. Clinical plans were forward-calculated on verification CTs to assess robustness relative to anatomic changes. Setup errors were assessed by forward-calculating clinical plans with a ±5-mm (left–right, anterior–posterior, superior–inferior) isocenter shift on the planning CT. Differences in clinical target volume and organ at risk dose–volume histogram (DHV) indicators between plans were tested for significance using an appropriate Wilcoxon test (P<.05). Results: Dosimetrically, PBS plans were statistically different from VMAT plans, showing greater organ at risk sparing. However, the bladder was statistically identical among LAT and VMAT plans. The clinical target volume coverage was statistically identical among all plans. The robustness test found that all DVH indicators for PBS and VMAT plans were robust, except the LAT's genitalia (V5, V35). The verification CT plans showed that all DVH indicators were robust. Conclusions: Pencil beam scanning plans were found to be as robust as VMAT plans relative to interfractional changes during treatment when posterior beam angles and appropriate range margins are used. Pencil beam scanning dosimetric gains in the bowel (V15, V20) over VMAT suggest that using PBS to treat rectal cancer may reduce radiation treatment–related toxicity.« less
  • Radiation therapy for head and neck malignancies can have side effects that impede quality of life. Theoretically, proton therapy can reduce treatment-related morbidity by minimizing the dose to critical normal tissues. We evaluated the feasibility of spot-scanning proton therapy for head and neck malignancies and compared dosimetry between those plans and intensity-modulated radiation therapy (IMRT) plans. Plans from 5 patients who had undergone IMRT for primary tumors of the head and neck were used for planning proton therapy. Both sets of plans were prepared using computed tomography (CT) scans with the goals of achieving 100% of the prescribed dose tomore » the clinical target volume (CTV) and 95% to the planning TV (PTV) while maximizing conformity to the PTV. Dose-volume histograms were generated and compared, as were conformity indexes (CIs) to the PTVs and mean doses to the organs at risk (OARs). Both modalities in all cases achieved 100% of the dose to the CTV and 95% to the PTV. Mean PTV CIs were comparable (0.371 IMRT, 0.374 protons, p = 0.953). Mean doses were significantly lower in the proton plans to the contralateral submandibular (638.7 cGy IMRT, 4.3 cGy protons, p = 0.002) and parotid (533.3 cGy IMRT, 48.5 cGy protons, p = 0.003) glands; oral cavity (1760.4 cGy IMRT, 458.9 cGy protons, p = 0.003); spinal cord (2112.4 cGy IMRT, 249.2 cGy protons, p = 0.002); and brainstem (1553.52 cGy IMRT, 166.2 cGy protons, p = 0.005). Proton plans also produced lower maximum doses to the spinal cord (3692.1 cGy IMRT, 2014.8 cGy protons, p = 0.034) and brainstem (3412.1 cGy IMRT, 1387.6 cGy protons, p = 0.005). Normal tissue V{sub 10}, V{sub 30}, and V{sub 50} values were also significantly lower in the proton plans. We conclude that spot-scanning proton therapy can significantly reduce the integral dose to head and neck critical structures. Prospective studies are underway to determine if this reduced dose translates to improved quality of life.« less
  • Purpose: Conventional proton therapy with passively scattered beams is used to treat a number of tumor sites, including prostate cancer. Spot scanning proton therapy is a treatment delivery means that improves conformal coverage of the clinical target volume (CTV). Placement of individual spots within a target is dependent on traversed tissue density. Errors in patient alignment perturb dose distributions. Moreover, there is a need for a rational planning approach that can mitigate the dosimetric effect of random alignment errors. We propose a treatment planning approach and then analyze the consequences of various simulated alignment errors on prostate treatments. Methods andmore » Materials: Ten control patients with localized prostate cancer underwent treatment planning for spot scanning proton therapy. After delineation of the clinical target volume, a scanning target volume (STV) was created to guide dose coverage. Errors in patient alignment in two axes (rotational and yaw) as well as translational errors in the anteroposterior direction were then simulated, and dose to the CTV and normal tissues were reanalyzed. Results: Coverage of the CTV remained high even in the setting of extreme rotational and yaw misalignments. Changes in the rectum and bladder V45 and V70 were similarly minimal, except in the case of translational errors, where, as a result of opposed lateral beam arrangements, much larger dosimetric perturbations were observed. Conclusions: The concept of the STV as applied to spot scanning radiation therapy and as presented in this report leads to robust coverage of the CTV even in the setting of extreme patient misalignments.« less
  • Purpose: To evaluate planning methods for anal canal cancer and compare the results of 9-field Intensity Modulated Radiotherapy (IMRT), Volumetric Modulated Arc Therapy (Varian, RapidArc), and Proton Pencil Beam Scanning (PBS). Methods: We generated plans with IMRT, RapidArc (RA) and PBS for twenty patients for both initial phase including nodes and cone down phase of treatment using Eclipe (Varian). We evaluated the advantage of each technique for each phase. RA plans used 2 to 4 arcs and various collimator orientations. PBS used two posterior oblique fields. We evaluated the plans comparing dose volume histogram (DVH), locations of hot spots, andmore » PTV dose conformity. Results: Due to complex shape of target, for RA plans, multiple arcs (>2) are required to achieve optimal PTV conformity. When the PTV exceeds 15 cm in the superior-inferior direction, limitations of deliverability start to dominate. The PTV should be divided into a superior and an inferior structure. The optimization is performed with fixed jaws for each structure and collimator set to 90 degrees for the inferior PTV. Proton PBS plans show little advantage in small bowel sparing when treating the nodes. However, PBS plan reduces volumetric dose to the bladder at the cost of higher doses to the perineal skin. IMRT plans provide good target conformity, but they generate hot spots outside of the target volume. Conclusion: When using one planning technique for entire course of treatment, Multiple arc (>2) RA plans are better as compared to IMRT and PBS plans. When combining techniques, RA for the initial phase in combination with PBS for the cone down phase results in the most optimal plans.« less
  • Purpose: Eclipse proton Monte Carlo AcurosPT 13.7 was commissioned and experimentally validated for an IBA dedicated PBS nozzle in water. Topas 1.3 was used to isolate the cause of differences in output and penumbra between simulation and experiment. Methods: The spot profiles were measured in air at five locations using Lynx. PTW-34070 Bragg peak chamber (Freiburg, Germany) was used to collect the relative integral Bragg peak for 15 proton energies from 100 MeV to 225 MeV. The phase space parameters (σx, σθ, ρxθ) number of protons per MU, energy spread and calculated mean energy provided by AcurosPT were identically implementedmore » into Topas. The absolute dose, profiles and field size factors measured using ionization chamber arrays were compared with both AcurosPT and Topas. Results: The beam spot size, σx, and the angular spread, σθ, in air were both energy-dependent: in particular, the spot size in air at isocentre ranged from 2.8 to 5.3 mm, and the angular spread ranged from 2.7 mrad to 6 mrad. The number of protons per MU increased from ∼9E7 at 100 MeV to ∼1.5E8 at 225 MeV. Both AcurosPT and TOPAS agree with experiment within 2 mm penumbra difference or 3% dose difference for scenarios including central axis depth dose and profiles at two depths in multi-spot square fields, from 40 to 200 mm, for all the investigated single-energy and multi-energy beams, indicating clinically acceptable source model and radiation transport algorithm in water. Conclusion: By comparing measured data and TOPAS simulation using the same source model, the AcurosPT 13.7 was validated in water within 2 mm penumbra difference or 3% dose difference. Benchmarks versus an independent Monte Carlo code are recommended to study the agreement in output, filed size factors and penumbra differences. This project is partially supported by the Varian grant under the master agreement between University of Pennsylvania and Varian.« less