Application of LiMgPO4 crystal for proton beam quality control in radiotherapy.

The radioluminescence (RL) emitted by LiMgPO4 detector under proton beam irradiation was investigated in real time at the radiotherapy facility in the Institute of Nuclear Physics Polish Academy of Sciences in Krakow. The facility uses protons accelerated by the AIC-144 isochronous cyclotron up to the energy of 60 MeV. The measurements of RL were carried out using a remote optical fiber device with a luminophore detector and photomultiplier located at opposite ends of the optical fiber. A thin slice of LiMgPO4 doped with Tm (1.2 mol%) crystal was exposed to the proton beam. The tested detector allowed for the measurement of proton beam current, flux fluence and determination of proton beam time structure parameters. The investigation of LiMgPO4 crystal showed its high sensitivity, fast reaction time to irradiation and possibility of application as the detector for control of proton beam parameters.

Calibration method and performance of a time-of-flight detector to measure absolute beam energy in proton therapy.

BACKGROUND: The beam energy is one of the most significant parameters in particle therapy since it is directly correlated to the particles' penetration depth inside the patient. Nowadays, the range accuracy is guaranteed by offline routine quality control checks mainly performed with water phantoms, 2D detectors with PMMA wedges, or multi-layer ionization chambers. The latter feature low sensitivity, slow collection time, and response dependent on external parameters, which represent limiting factors for the quality controls of beams delivered with fast energy switching modalities, as foreseen in future treatments. In this context, a device based on solid-state detectors technology, able to perform a direct and absolute beam energy measurement, is proposed as a viable alternative for quality assurance measurements and beam commissioning, paving the way for online range monitoring and treatment verification. PURPOSE: This work follows the proof of concept of an energy monitoring system for clinical proton beams, based on Ultra Fast Silicon Detectors (featuring tenths of ps time resolution in 50 µm active thickness, and single particle detection capability) and time-of-flight techniques. An upgrade of such a system is presented here, together with the description of a dedicated self-calibration method, proving that this second prototype is able to assess the mean particles energy of a monoenergetic beam without any constraint on the beam temporal structure, neither any a priori knowledge of the beam energy for the calibration of the system. METHODS: A new detector geometry, consisting of sensors segmented in strips, has been designed and implemented in order to enhance the statistics of coincident protons, thus improving the accuracy of the measured time differences. The prototype was tested on the cyclotron proton beam of the Trento Protontherapy Center (TPC). In addition, a dedicated self-calibration method, exploiting the measurement of monoenergetic beams crossing the two telescope sensors for different flight distances, was introduced to remove the systematic uncertainties independently from any external reference. RESULTS: The novel calibration strategy was applied to the experimental data collected at TPC (Trento) and CNAO (Pavia). Deviations between measured and reference beam energies in the order of a few hundreds of keV with a maximum uncertainty of 0.5 MeV were found, in compliance with the clinically required water range accuracy of 1 mm. CONCLUSIONS: The presented version of the telescope system, minimally perturbative of the beam, relies on a few seconds of acquisition time to achieve the required clinical accuracy and therefore represents a feasible solution for beam commission, quality assurance checks, and online beam energy monitoring.

Quality assurance of scanned proton beams at different gantry angles using an ionization chamber array in a rotational phantom.

PURPOSE: To implement a single set-up monthly QA procedure for 9 different beam parameters at different gantry angles and evaluate its clinical implementation over a 12 month period. METHODS: We developed a QA procedure using an array detector (PTW Octavius 1500XDR) embedded in a rotational unit (PTW Octavius 4D) at our proton facility. With a single set-up we can monitor field central axis position, field symmetry, field size, flatness, penumbrae, output, spot size, spot position and range at different gantry angles (AAPM TG 224). The set-up is irradiated with homogenous 2D fields with dynamic aperture and spot patterns at five gantry angles. A modular top is used to check the range consistency. Absolute γ analysis were performed to compare measured dose distributions to calculated dose. All other parameters are directly extracted from the measurements. Additionally, the sensitivity of the set-up to small changes in beam parameters were compared to the Lynx detector (IBA). RESULTS: Over a 12 month period, output, symmetry, and flatness were within ± 2 %; FWHM, spot positions, penumbra widths, and central axis fields were within ± 1 mm. Range differences were all within 1/2 of the energy spacing (±0.6 MeV) relative to baseline. Most (2 %, 2 mm) γ-analysis showed agreement scores higher than 90 %. The sensitivity is comparable to the Lynx detector and measurement time is reduced by 40 %. CONCLUSION: The time-efficient monthly QA procedure that we developed can accurately be used to measure a large range of beam parameters at different gantry angles, within the TG 224 AAPM recommendations.

The Value of On-Site Proton Audits.

PURPOSE: This study aimed to highlight the value and key findings of on-site proton audits. METHODS AND MATERIALS: The authors performed 38 on-site measurement-based peer reviews of proton centers participating in National Cancer Institute-funded clinical trials. The reviews covered beam calibration, lateral and depth measurements, mechanical checks, treatment planning and clinical practice, and quality assurance (QA) practices. Program deficiencies were noted, and recommendations were made about ways institutions could improve their practices. RESULTS: Institutions received an average of 3 (range, 1-8) recommendations for practice improvements. The number of deficiencies did not decrease over time, highlighting the continued need for this type of peer review. The most common deficiencies were for Task Group-recommended QA compliance (97% of centers), computed tomography number (CTN) to relative linear stopping power conversion (59%), and QA procedures (53%). In addition, 32% of institutions assessed failed at least 1 lateral beam profile measurement (<90% of pixels passing 3% [global]/3 mm; 10% threshold), despite passing internal QA measurements. These failures occurred for several different plan configurations (large, small, shallow, and deep targets) and at different depths in the beam path (proximal to target, central, and distal). CTN to relative linear stopping power conversion curves showed deviations at low, mid, and high CTNs and highlighted areas of inconsistency between proton centers, with many centers falling outside of 2 sigma of the mean curve of their peers. All deficiencies from the peer review were discussed with the institutions, and many implemented dosimetric treatment planning and practice changes to improve the accuracy of their system and consistency with other institutions. CONCLUSIONS: This peer review program has been integral in confirming and promoting consistency and best practice across proton centers for clinical trials, minimizing deviations for outcomes data.

Dosimetric Comparison of Helical Tomotherapy and Intensity-Modulated Proton Therapy in Hippocampus- and Scalp-Sparing Whole Brain Radiotherapy.

Objective: Cognitive decline and alopecia after radiotherapy are challenging problems. We aimed to compare whole brain radiotherapy (WBRT) plans reducing radiation dose to the hippocampus and scalp between helical tomotherapy (HT) and intensity-modulated proton therapy (IMPT). Methods: We conducted a planning study of WBRT for 10 patients. The clinical target volume was defined as the whole brain excluding the hippocampus avoidance (HA) region. The prescribed dose was 30 Gy in 10 fractions to cover 95% of the target. Constraint goals were defined for the target and organs at risk (OAR). Results: Both techniques met the dose constraints for the target and OAR. However, the coverage of the target (dose covering 95% [D95%] and 98% [D98%] of the volume) were better in IMPT than HT (HT vs IMPT: D95%, 29.9 Gy vs 30.0 Gy, P < .001; D98%, 26.7 Gy vs 28.1 Gy, P = .002). The homogeneity and conformity of the target were also better in IMPT than HT (HT vs IMPT: homogeneity index, 1.50 vs 1.28, P < .001; conformity index, 1.30 vs 1.14, P < .001). IMPT reduced the D100% of the hippocampus by 59% (HT vs IMPT: 9.3 Gy vs 3.8 Gy, P < .001) and reduced the Dmean of the hippocampus by 37% (HT vs IMPT: 11.1 Gy vs 7.0 Gy, P < .001) compared with HT. The scalp IMPT reduced the percentage of the volume receiving at least 20 Gy (V20Gy) and V10Gy compared with HT (HT vs IMPT: V20Gy, 56.7% vs 6.6%, P < .001; V10Gy, 90.5% vs 37.1%, P < .001). Conclusion: Both techniques provided acceptable target dose coverage. Especially, IMPT achieved excellent hippocampus- and scalp-sparing. HA-WBRT using IMPT is a promising treatment to prevent cognitive decline and alopecia.

Optimizing oropharyngeal cancer management by using proton beam therapy: trends of cost-effectiveness.

BACKGROUND: Proton beam therapy (PBT) is a new-emerging cancer treatment in China but its treatment costs are high and not yet covered by Chinese public medical insurance. The advanced form of PBT, intensity-modulated proton radiation therapy (IMPT), has been confirmed to reduce normal tissue complication probability (NTCP) as compared to conventional intensity-modulated photon-radiation therapy (IMRT) in patients with oropharyngeal cancer (OPC). Herein, we evaluated the cost-effectiveness and applicability of IMPT versus IMRT for OPC patients in China, aiming at guiding the proper use of PBT. METHODS: A 7-state Markov model was designed for analysis. Base-case evaluation was performed on a 56-year-old (median age of OPC in China) patient under the assumption that IMPT could provide a 25% NTCP-reduction in long-term symptomatic dysphagia and xerostomia. Model robustness was examined using probabilistic sensitivity analysis, cohort analysis, and tornado diagram. One-way sensitivity analyses were conducted to identify the cost-effective scenarios. IMPT was considered as cost-effective if the incremental cost-effectiveness ratio (ICER) was below the societal willingness-to-pay (WTP) threshold. RESULTS: Compared with IMRT, IMPT provided an extra 0.205 quality-adjusted life-year (QALY) at an additional cost of 34,926.6 US dollars ($), and had an ICER of $170,082.4/ QALY for the base case. At the current WTP of China ($33,558 / QALY) and a current IMPT treatment costs of $50,000, IMPT should provide a minimum NTCP-reduction of 47.5, 50.8, 55.6, 63.3 and 77.2% to be considered cost-effective for patient age levels of 10, 20, 30, 40 and 50-year-old, respectively. For patients at the median age level, reducing the current IMPT costs ($50,000) to a $30,000 level would make the minimum NTCP-reduction threshold for "cost-effective" decrease from 91.4 to 44.6%, at the current WTP of China (from 69.0 to 33.5%, at a WTP of $50,000 / QALY; and from 39.7 to 19.1%, at a WTP of $100,000 / QALY). CONCLUSIONS: Cost-effective scenarios of PBT exist in Chinese OPC patients at the current WTP of China. Considering a potential upcoming increase in PBT use in China, such cost-effective scenarios may further expand if a decrease of proton treatment costs occurs or an increase of WTP level.

Optimizing proton minibeam radiotherapy by interlacing and heterogeneous tumor dose on the basis of calculated clonogenic cell survival.

Proton minibeam radiotherapy (pMBRT) is a spatial fractionation method using sub-millimeter beams at center-to-center (ctc) distances of a few millimeters to widen the therapeutic index by reduction of side effects in normal tissues. Interlaced minibeams from two opposing or four orthogonal directions are calculated to minimize side effects. In particular, heterogeneous dose distributions applied to the tumor are investigated to evaluate optimized sparing capabilities of normal tissues at the close tumor surrounding. A 5 cm thick tumor is considered at 10 cm depth within a 25 cm thick water phantom. Pencil and planar minibeams are interlaced from two (opposing) directions as well as planar beams from four directions. An initial beam size of σ0 = 0.2 mm (standard deviation) is assumed in all cases. Tissue sparing potential is evaluated by calculating mean clonogenic cell survival using a linear-quadratic model on the calculated dose distributions. Interlacing proton minibeams for homogeneous irradiation of the tumor has only minor benefits for the mean clonogenic cell survival compared to unidirectional minibeam irradiation modes. Enhanced mean cell survival, however, is obtained when a heterogeneous dose distribution within the tumor is permitted. The benefits hold true even for an elevated mean tumor dose, which is necessary to avoid cold spots within the tumor in concerns of a prescribed dose. The heterogeneous irradiation of the tumor allows for larger ctc distances. Thus, a high mean cell survival of up to 47% is maintained even close to the tumor edges for single fraction doses in the tumor of at least 10 Gy. Similar benefits would result for heavy ion minibeams with the advantage of smaller minibeams in deep tissue potentially offering even increased tissue sparing. The enhanced mean clonogenic cell survival through large ctc distances for interlaced pMBRT with heterogeneous tumor dose distribution results in optimum tissue sparing potential. The calculations show the largest enhancement of the mean cell survival in normal tissue for high-dose fractions. Thus, hypo-fractionation or even single dose fractions become possible for tumor irradiation. A widened therapeutic index at big cost reductions is offered by interlaced proton or heavy ion minibeam therapy.

TriB-RT: Simultaneous optimization of photon, electron and proton beams.

PURPOSE: To develop a novel treatment planning process (TPP) with simultaneous optimization of modulated photon, electron and proton beams for improved treatment plan quality in radiotherapy. METHODS: A framework for fluence map optimization of Monte Carlo (MC) calculated beamlet dose distributions is developed to generate treatment plans consisting of photon, electron and spot scanning proton fields. Initially, in-house intensity modulated proton therapy (IMPT) plans are compared to proton plans created by a commercial treatment planning system (TPS). A triple beam radiotherapy (TriB-RT) plan is generated for an exemplary academic case and the dose contributions of the three particle types are investigated. To investigate the dosimetric potential, a TriB-RT plan is compared to an in-house IMPT plan for two clinically motivated cases. Benefits of TriB-RT for a fixed proton beam line with a single proton field are investigated. RESULTS: In-house optimized IMPT are of at least equal or better quality than TPS-generated proton plans, and MC-based optimization shows dosimetric advantages for inhomogeneous situations. Concerning TriB-RT, for the academic case, the resulting plan shows substantial contribution of all particle types. For the clinically motivated case, improved sparing of organs at risk close to the target volume is achieved compared to IMPT (e.g. myelon and brainstem [Formula: see text] -37%) at cost of an increased low dose bath (healthy tissue V 10% +22%). In the scenario of a fixed proton beam line, TriB-RT plans are able to compensate the loss in degrees of freedom to substantially improve plan quality compared to a single field proton plan. CONCLUSION: A novel TPP which simultaneously optimizes photon, electron and proton beams was successfully developed. TriB-RT shows the potential for improved treatment plan quality and is especially promising for cost-effective single-room proton solutions with a fixed beamline in combination with a conventional linac delivering photon and electron fields.

A Beam-Angle-Selection Method to Improve Inter-Fraction Motion Robustness for Lung Tumor Irradiation With Passive Proton Scattering.

In terms of dose distribution, protons are more sensitive to range variations than photons due to their unique properties. The aim of this study was to develop a method to identify patient-specific robust proton beam angles for lung tumor irradiation by investigating the association between water equivalent thickness (WET) variation and inter-fraction motion-induced target dose degradation. Using 3-dimensional computed tomography (3D-CT) images, the impact of WET variations on the target dose coverage of a series of coplanar proton beams was evaluated for 4 patients with lung cancer. Using ray tracing, WET maps, or WET baseline, were estimated for the internal target volume (ITV) at every 5° gantry interval in the axial plane. After calculating the WET baseline, the planning CT was shifted 5 mm in each anterior-posterior (AP), superior-inferior (SI), and left-right (LR) direction, yielding a total of 6 shifted CTs, and differential WET maps between the planning CT and each shifted CT were calculated. Target dose differences were associated with the average WET change between the original planning CT and the shifted CTs for all 360° gantry rotation beams. Target and OAR dose metrics in the ΔWET-guided plans were compared with those of the clinical plans. The WET variation maps showed areas of both high and low WET variations, with overall similar patterns yet individual differences reflecting tumor position differences. For all 4 patients investigated in this study, the coplanar plans demonstrated a strong correlation between WET changes and ITV dose reductions. Target dose coverage was more stable with the ΔWET-guided plan while OAR doses were comparable to the clinical plan. The WET variation maps have been used in this pilot study to identify proton beam angles that are either sensitive or robust to WET changes in proton passive scattering. This work demonstrates the feasibility of using WET variation maps to assist the planner in inter-fraction motion-robust proton beam angle selection.

Accounting for Range Uncertainties in the Optimization of Combined Proton-Photon Treatments Via Stochastic Optimization.

PURPOSE: Proton treatment slots are a limited resource. Combined proton-photon treatments, in which most fractions are delivered with photons and only a few with protons, may represent a practical solution to optimize the allocation of proton resources over the patient population. We demonstrate how a limited number of proton fractions can be optimally used in multimodality treatments and address the issue of the robustness of combined treatments against proton range uncertainties. METHODS AND MATERIALS: Combined proton-photon treatments are planned by simultaneously optimizing intensity modulated radiation therapy and proton therapy plans while accounting for the fractionation effect through the biologically effective dose model. The method was investigated for different tumor sites (a spinal metastasis, a sacral chordoma, and an atypical meningioma) in which organs at risk (OARs) were located within or near the tumor. Stochastic optimization was applied to mitigate range uncertainties. RESULTS: In optimal combinations, proton and photon fractions deliver similar doses to OARs overlaying the target volume to protect these dose-limiting normal tissues through fractionation. Meanwhile, parts of the tumor are hypofractionated with protons. Thus, the total dose delivered with photons is reduced compared with simple combinations in which each modality delivers the prescribed dose per fraction to the target volume. The benefit of optimal combinations persists when range errors are accounted for via stochastic optimization. CONCLUSIONS: Limited proton resources are optimally used in combined treatments if parts of the tumor are hypofractionated with protons and near-uniform fractionation is maintained in serial OARs. Proton range uncertainties can be efficiently accounted for through stochastic optimization and are not an obstacle for clinical application.

Measurement-based study on characterizing symmetric and asymmetric respiratory motion interplay effect on target dose distribution in the proton pencil beam scanning.

Pencil beam scanning proton therapy makes possible intensity modulation, resulting in improved target dose conformity and organ-at-risk (OAR) dose sparing. This benefit, however, results in increased sensitivity to certain clinical and beam delivery parameters, such as respiratory motion. These effects can cause plan degeneration, which could lead to decreased tumor dose or increased OAR dose. This study evaluated the measurements of proton pencil beam scanning delivery made with a 2D ion chamber array in solid water on a 1D motion platform, where respiratory motion was simulated using sine and cosine4 waves representing sinusoidal symmetric and realistic asymmetric breathing motions, respectively. Motion amplitudes were 0.5 cm and 1 cm corresponding to 1 cm and 2 cm of maximum respiratory excursions, respectively, with 5 sec fixed breathing cycle. The treatment plans were created to mimic spherical targets of 3 cm or 10 cm diameter located at 5 cm or 1 cm depth in solid water phantom. A reference RBE dose of 200 cGy per fraction was delivered in 1, 5, 10, and 15 fractions for each dataset. We evaluated dose conformity and uniformity at the center plane of targets by using the Conformation Number and the Homogeneity Index, respectively. Results indicated that dose conformity as well as homogeneity was more affected by motion for smaller targets. Dose conformity was better achieved for symmetric breathing patterns than asymmetric breathing patterns regardless of the number of fractions. The presence of a range shifter with shallow targets reduced the motion effect by improving dose homogeneity. While motion effects are known to be averaged out over the course of multifractional treatments, this might not be true for proton pencil beam scanning under asymmetrical breathing pattern.

A fast robust optimizer for intensity modulated proton therapy using GPU.

Robust optimization has been shown to be effective for stabilizing treatment planning in intensity modulated proton therapy (IMPT), but existing algorithms for the optimization process is time-consuming. This paper describes a fast robust optimization tool that takes advantage of the GPU parallel computing technologies. The new robust optimization model is based on nine boundary dose distributions - two for ±range uncertainties, six for ±set-up uncertainties along anteroposterior (A-P), lateral (R-L) and superior-inferior (S-I) directions, and one for nominal situation. The nine boundary influence matrices were calculated using an in-house finite size pencil beam dose engine, while the conjugate gradient method was applied to minimize the objective function. The proton dose calculation algorithm and the conjugate gradient method were tuned for heterogeneous platforms involving the CPU host and GPU device. Three clinical cases - one head and neck cancer case, one lung cancer case, and one prostate cancer case - were investigated to demonstrate the clinical feasibility of the proposed robust optimizer. Compared with results from Varian Eclipse (version 13.3), the proposed method is found to be conducive to robust treatment planning that is less sensitive to range and setup uncertainties. The three tested cases show that targets can achieve high dose uniformity while organs at risks (OARs) are in better protection against setup and range errors. Based on the CPU + GPU heterogeneous platform, the execution times of the head and neck cancer case and the prostate cancer case are much less than half of Eclipse, while the run time of the lung cancer case is similar to that of Eclipse. The fast robust optimizer developed in this study can improve the reliability of traditional proton treatment planning in a much faster speed, thus making it possible for clinical utility.

ACR-ASTRO Practice Parameter for the Performance of Proton Beam Radiation Therapy.

AIM/OBJECTIVES/BACKGROUND: The American College of Radiology (ACR) and the American Society for Radiation Oncology (ASTRO) have jointly developed the following practice parameter for proton beam radiation therapy. Proton radiotherapy is the application of a high-energy proton beam to a patient in a clinical setting with therapeutic intent. Proton radiotherapy may permit improved therapeutic ratios with lower doses to sensitive normal structures and greater dose to target tumor tissues. METHODS: A literature search was performed to identify published articles regarding clinical outcomes, reviews, quality assurance methodologies, and guidelines and standards for proton radiation therapy. Selected articles are referenced in the text. The following recommendations are based on firsthand experiences of multiple clinical authorities who employ proton therapy and have been peer reviewed by experts at different practicing institutions. RESULTS: This practice parameter is developed to serve as a tool in the appropriate application of this evolving technology in the care of cancer patients or other patients with conditions where radiation therapy is indicated. It addresses clinical implementation of proton radiation therapy, including personnel qualifications, quality assurance standards, indications, and suggested documentation. CONCLUSIONS: This practice parameter is a tool to guide technical use of proton therapy and does not assess the relative clinical indication of proton radiotherapy when compared with other forms of radiotherapy, but to focus on the best practices required to deliver proton therapy safely and effectively, when clinically indicated. Costs of proton treatments are high, and the economic costs of proton radiotherapy may also need to be considered.

Benchmarking a commercial proton therapy solution: The Paul Scherrer Institut experience.

OBJECTIVE: For the past 20 years, Paul Scherrer Institut (PSI) has treated more than 1500 patients with deep-seated tumors using PSI-Plan, an in-house developed treatment planning system (TPS) used for proton beam scanning proton therapy, in combination with its home-built gantries. The goal of the present work is to benchmark the performance of a new TPS/Gantry system for proton therapy centers which have established already a baseline standard of care. METHODS AND MATERIALS: A total of 31 cases (=52 plans) distributed around 7 anatomical sites and 12 indications were randomly selected and re-planned using Eclipse™. The resulting plans were compared with plans formerly optimized in PSI-Plan, in terms of target coverage, plan quality, organ-at-risk (OAR) sparing and number of delivered pencil beams. RESULTS: Our results show an improvement on target coverage and homogeneity when using Eclipse™ while PSI-Plan showed superior plan conformity. As for OAR sparing, both TPS achieved the clinical constraints. The number of pencil beams required per plan was on average 3.4 times higher for PSI-Plan. CONCLUSION: Both systems showed a good capacity to produce satisfactory plans, with Eclipse™ being able to achieve better target coverage and plan homogeneity without compromising OARs. ADVANCES IN KNOWLEDGE: A benchmark between a clinically tested and validated system with a commercial solution is of interest for emerging proton therapy, equipped with commercial systems and no previous experience with proton beam scanning.

Transitioning from measurement-based to combined patient-specific quality assurance for intensity-modulated proton therapy.

OBJECTIVE: This study is part of ongoing efforts aiming to transit from measurement-based to combined patient-specific quality assurance (PSQA) in intensity-modulated proton therapy (IMPT). A Monte Carlo (MC) dose-calculation algorithm is used to improve the independent dose calculation and to reveal the beam modeling deficiency of the analytical pencil beam (PB) algorithm. METHODS: A set of representative clinical IMPT plans with suboptimal PSQA results were reviewed. Verification plans were recalculated using an MC algorithm developed in-house. Agreements of PB and MC calculations with measurements that quantified by the γ passing rate were compared. RESULTS: The percentage of dose planes that met the clinical criteria for PSQA (>90% γ passing rate using 3%/3 mm criteria) increased from 71.40% in the original PB calculation to 95.14% in the MC recalculation. For fields without beam modifiers, nearly 100% of the dose planes exceeded the 95% γ passing rate threshold using the MC algorithm. The model deficiencies of the PB algorithm were found in the proximal and distal regions of the SOBP, where MC recalculation improved the γ passing rate by 11.27% (p < 0.001) and 16.80% (p < 0.001), respectively. CONCLUSIONS: The MC algorithm substantially improved the γ passing rate for IMPT PSQA. Improved modeling of beam modifiers would enable the use of the MC algorithm for independent dose calculation, completely replacing additional depth measurements in IMPT PSQA program. For current users of the PB algorithm, further improving the long-tail modeling or using MC simulation to generate the dose correction factor is necessary. ADVANCES IN KNOWLEDGE: We justified a change in clinical practice to achieve efficient combined PSQA in IMPT by using the MC algorithm that was experimentally validated in almost all the clinical scenarios in our center. Deficiencies in beam modeling of the current PB algorithm were identified and solutions to improve its dose-calculation accuracy were provided.

Statistical evaluation of worst-case robust optimization intensity-modulated proton therapy plans using an exhaustive sampling approach.

PURPOSE: To assess the worst-case robust optimization IMPT plans with setup and range uncertainties and to test the hypothesis that the worst-case robust optimization strategies could cover most possible setup and range uncertainties in the real scenarios. METHODS: We analyzed the nominal and worst-case robust optimization IMPT plans of seven patients with head and neck cancer patients. To take uncertainties into account for the dose calculation, we performed a comprehensive simulation in which the dose was recalculated 625 times per given plan using Gaussian systematic setup and proton range uncertainties. Subsequently, based on the simulation results, we calculated the target coverage in all perturbation scenarios, as well as the ratios of target coverage located within the threshold of eight worst-case scenarios. We set the criteria for the optimized plan to be the ratios of 1) the dose delivered to 95% (D95%) of clinical target volumes 1 and 2 (CTV1 and CTV2) above 95% of the prescribed dose, and 2) the D95% of clinical target volume 3 (CTV3) above 90% of the prescribed dose in worst-case situations. RESULTS: The probability that the perturbed-dose indices of the CTVs in each scenario were within the worst-case scenario limits ranged from 89.51 to 91.22% for both the nominal and worst-case robust optimization IMPT plans. A quartile analysis showed that the selective robust optimization IMPT plans all had higher D95% values for CTV1, CTV2, and CTV3 than did the nominal IMPT plans. CONCLUSIONS: The worst-case strategy for robust optimization is adequately models and covers most of the setup and range uncertainties for the IMPT treatment of head and neck patients in our center.

AAPM task group 224: Comprehensive proton therapy machine quality assurance.

PURPOSE:  Task Group (TG) 224 was established by the American Association of Physicists in Medicine's Science Council under the Radiation Therapy Committee and Work Group on Particle Beams. The group was charged with developing comprehensive quality assurance (QA) guidelines and recommendations for the three commonly employed proton therapy techniques for beam delivery: scattering, uniform scanning, and pencil beam scanning. This report supplements established QA guidelines for therapy machine performance for other widely used modalities, such as photons and electrons (TG 142, TG 40, TG 24, TG 22, TG 179, and Medical Physics Practice Guideline 2a) and shares their aims of ensuring the safe, accurate, and consistent delivery of radiation therapy dose distributions to patients. METHODS:  To provide a basis from which machine-specific QA procedures can be developed, the report first describes the different delivery techniques and highlights the salient components of the related machine hardware. Depending on the particular machine hardware, certain procedures may be more or less important, and each institution should investigate its own situation. RESULTS:  In lieu of such investigations, this report identifies common beam parameters that are typically checked, along with the typical frequencies of those checks (daily, weekly, monthly, or annually). The rationale for choosing these checks and their frequencies is briefly described. Short descriptions of suggested tools and procedures for completing some of the periodic QA checks are also presented. CONCLUSION:  Recommended tolerance limits for each of the recommended QA checks are tabulated, and are based on the literature and on consensus data from the clinical proton experience of the task group members. We hope that this and other reports will serve as a reference for clinical physicists wishing either to establish a proton therapy QA program or to evaluate an existing one.

Hybrid proton-photon inverse optimization with uniformity-regularized proton and photon target dose.

The goal of radiation therapy is to deliver tumoricidal dose to clinical target volume (CTV) while sparing organs-at-risk (OAR). We hypothesize that the joint use of proton and photon radiation therapy via appropriate hybrid proton-photon inverse planning method will be more favorable than proton or photon therapy alone, in terms of optimized combination of CTV coverage and OAR sparing. This work develops hybrid proton-photon inverse optimization method that simultaneously optimizes proton and photon variables. To account for delivery uncertainty, proton dose is targeted at CTV using robust optimization, and photon dose is targeted at either CTV using robust optimization or planning target volume (PTV) using the same setup shifts. The optimization objectives enforce OAR sparing and uniform CTV coverage for the total dose, while imposing uniform-dose regularization at targets for both the proton and photon component in order for both components to be individually deliverable. The hybrid problem with dose-volume-histogram (DVH) constraints is nonconvex and solved by iterative convex relaxations of DVH constraints and alternating direction method of multipliers (ADMM). Preliminary results suggest the hybrid proton-photon planning potentially improves proton or photon planning in terms of optimized combination of CTV coverage and OAR sparing.