First experimental results of motion mitigation by continuous line scanning of protons.

Mitigation of organ motion in active, scanning proton therapy is a challenge. One of the easiest methods to implement is re-scanning, where a treatment plan is applied several times with accordingly smaller weights. As a consequence, motion effects are averaged out. For discrete spot scanning, a major drawback of this method is the treatment time, which increases linearly with the number of re-scans. Continuous line scanning, on the other hand, eliminates the dead time between the positioning of each beam, and in this work, continuous line scanning has been investigated experimentally from the point of view of dose, penumbral width and its effectiveness for re-scanning. As shown by measurements in a homogeneous phantom, dose distributions delivered by continuous line scanning were comparable with those of discrete spot scanning for both geometric and realistic targets, with only a modest degradation of lateral penumbra in the direction of scanning. In addition, delivered dose levels have also been found to agree well between discrete and line scanning. With continuous line scanning, however, more re-scans could be applied without the artefacts seen in discrete spot scanning, with motions of up to 1 cm peak-to-peak amplitude being mitigated by 10 re-scans. For larger motion, in the interest of reducing the volume of irradiated normal tissue re-scanning should be combined with other motion mitigation techniques such as gating or breath-hold.

The effectiveness of combined gating and re-scanning for treating mobile targets with proton spot scanning. An experimental and simulation-based investigation.

Organ motion is one of the major obstacles in radiotherapy and charged particle therapy. Even more so, the theoretical advantages of dose distributions in scanned ion beam therapy may be lost due to the interplay between organ motion and beam scanning. Several techniques for dealing with this problem have been devised. In re-scanning, the target volume is scanned several times to average out the motion effects. In gating and breath-hold, dose is only delivered if the tumour is in a narrow window of position. Experiments have been performed to verify if gating and re-scanning are effective means of motion mitigation. Dose distributions were acquired in a lateral plane of a homogeneous phantom. For a spherical target volume and regular motion gating was sufficient. However, for realistic, irregular motion or a patient target volume, gating did not reduce the interplay effect to an acceptable level. Combining gating with re-scanning recovered the dose distributions. The simplest re-scanning approach, where a treatment plan is duplicated several times and applied in sequence, was not efficient. Simulations of different combinations of gating window sizes and re-scanning schemes revealed that reducing the gating window is the most efficient approach. However, very small gating windows are not robust for irregular motion.

Experimental verification of motion mitigation of discrete proton spot scanning by re-scanning.

In order to be able to treat mobile tumours with active, scanned proton therapy, adequate motion mitigation techniques have to be applied. Re-scanning is such an approach, where the interplay effect between tumour motion and treatment delivery is statistically smeared out. Different re-scanning methods have been used for the irradiation of a spherical target volume and motion amplitudes of up to 10 mm. The resulting dose distributions have been captured in two dimensions by imaging a scintillating screen at the iso-centre for different motion starting phases. Dose inhomogeneity increased approximately linearly with motion amplitude, while the influence of motion period and direction was small. Re-scanning the whole target volume reduced the interplay effect more than re-scanning only the iso-energy layers. Even for 10 mm motion amplitude, no hot or cold spots were seen for 10 re-scans of the whole volume. A fast energy change and fast beam scanning is vital for this kind of re-scanning, as available on Gantry 2 at the Paul Scherrer Institute. For larger motion amplitudes, re-scanning should be combined with gating, breath-hold or tracking to reduce the internal target volume.