Registration error of the liver CT using deformable image registration of MIM Maestro and Velocity AI.

BACKGROUND: Understanding the irradiated area and dose correctly is important for the reirradiation of organs that deform after irradiation, such as the liver. We investigated the spatial registration error using the deformable image registration (DIR) software products MIM Maestro (MIM) and Velocity AI (Velocity). METHODS: Image registration of pretreatment computed tomography (CT) and posttreatment CT was performed in 24 patients with liver tumors. All the patients received proton beam therapy, and the follow-up period was 4-14 (median: 10) months. We performed DIR of the pretreatment CT and compared it with that of the posttreatment CT by calculating the dislocation of metallic markers (implanted close to the tumors). RESULTS: The fiducial registration error was comparable in both products: 0.4-32.9 (9.3 ± 9.9) mm for MIM and 0.5-38.6 (11.0 ± 10.0) mm for Velocity, and correlated with the tumor diameter for MIM (r = 0.69, P = 0.002) and for Velocity (r = 0.68, P = 0.0003). Regarding the enhancement effect, the fiducial registration error was 1.0-24.9 (7.4 ± 7.7) mm for MIM and 0.3-29.6 (8.9 ± 7.2) mm for Velocity, which is shorter than that of plain CT (P = 0.04, for both). CONCLUSIONS: The DIR performance of both MIM and Velocity is comparable with regard to the liver. The fiducial registration error of DIR depends on the tumor diameter. Furthermore, contrast-enhanced CT improves the accuracy of both MIM and Velocity. INSTITUTIONAL REVIEW BOARD APPROVAL: H28-102; July 14, 2016 approved.

Formulation of Time-Dependent Cell Survival with Saturable Repairability of Radiation Damage.

This study aims to provide a model that compounds historically proposed ideas regarding cell survival irradiated with X rays or particles. The parameters used in this model have simple meanings and are closely related to cell death-related phenomena. The model is adaptable to a wide range of doses and dose rates and thus can consistently explain previously published cell survival data. The formulas of the model were derived by using five basic ideas: 1. "Poisson's law"; 2. "DNA affected damage"; 3. "repair"; 4. "clustered affected damage"; and 5. "saturation of reparability". The concept of affected damage is close to but not the same as the effect caused by the double-strand break (DSB). The parameters used in the formula are related to seven phenomena: 1. "linear coefficient of radiation dose"; 2. "probability of making affected damage"; 3. "cell-specific repairability", 4. "irreparable damage by adjacent affected damage"; 5. "recovery of temporally changed repairability"; 6. "recovery of simple damage which will make the affected damage"; 7. "cell division". By using the second parameter, this model includes cases where a single hit results in repairable-lethal and double-hit results in repairable-lethal. The fitting performance of the model for the experimental data was evaluated based on the Akaike information criterion, and practical results were obtained for the published experiments irradiated with a wide range of doses (up to several 10 Gy) and dose rates (0.17 Gy/h to 55.8 Gy/h). The direct association of parameters with cell death-related phenomena has made it possible to systematically fit survival data of different cell types and different radiation types by using crossover parameters.

A novel, end-to-end framework for avoiding collisions between the patient's body and gantry in proton therapy.

BACKGROUND: Administration of external radiation therapy via proton therapy systems carries a risk of occasional collisions between the patient's body and gantry, which is increased by the snout placed near the patient for better dose distribution. Although treatment planning software (TPS) can simulate controlled collisions, the computed tomography (CT) data used for treatment planning are insufficient given that collisions can occur outside the CT imaging region. Thus, imaging the three-dimensional (3D) surface outside the CT range and combining the data with those obtained by CT are essential for avoiding collisions. PURPOSE: To construct a prototype for 3D surface imaging and an end-to-end framework for preventing collisions between the patient's body and the gantry. METHODS: We obtained 3D surface data using a light sectioning method (LSM). By installing only cameras in front of the CT, we achieved LSM using the CT couch motion and preinstalled patient-positioning lasers. The camera image contained both sagittal and coronal lines, which are unnecessary for LSM and were removed by deep learning. We combined LSM 3D surface data and original CT data to create synthetic Digital Imaging and Communications in Medicine (DICOM) data. Subsequently, we compared the TPS snout auto-optimization using the original CT data with the synthetic DICOM data. RESULTS: The mean positional error for LSM of the arms and head was 0.7 ± 0.8  and 0.8 ± 0.8 mm for axial and sagittal imaging, respectively. The TPS snout auto-optimization indicated that the original CT data would cause collisions; however, the synthetic DICOM data prevented these collisions. CONCLUSIONS: The prototype system's acquisition accuracy for 3D surface data was approximately 1 mm, which was sufficient for the collision simulation. The use of a TPS with collision avoidance can help optimize the snout position using synthetic DICOM data. Our proposed method requires no external software for collision simulation and can be integrated into the clinical workflow to improve treatment planning efficiency.

Explainability and controllability of patient-specific deep learning with attention-based augmentation for markerless image-guided radiotherapy.

BACKGROUND: We reported the concept of patient-specific deep learning (DL) for real-time markerless tumor segmentation in image-guided radiotherapy (IGRT). The method was aimed to control the attention of convolutional neural networks (CNNs) by artificial differences in co-occurrence probability (CoOCP) in training datasets, that is, focusing CNN attention on soft tissues while ignoring bones. However, the effectiveness of this attention-based data augmentation has not been confirmed by explainable techniques. Furthermore, compared to reasonable ground truths, the feasibility of tumor segmentation in clinical kilovolt (kV) X-ray fluoroscopic (XF) images has not been confirmed. PURPOSE: The first aim of this paper was to present evidence that the proposed method provides an explanation and control of DL behavior. The second purpose was to validate the real-time lung tumor segmentation in clinical kV XF images for IGRT. METHODS: This retrospective study included 10 patients with lung cancer. Patient-specific and XF angle-specific image pairs comprising digitally reconstructed radiographs (DRRs) and projected-clinical-target-volume (pCTV) images were calculated from four-dimensional computer tomographic data and treatment planning information. The training datasets were primarily augmented by random overlay (RO) and noise injection (NI): RO aims to differentiate positional CoOCP in soft tissues and bones, and NI aims to make a difference in the frequency of occurrence of local and global image features. The CNNs for each patient-and-angle were automatically optimized in the DL training stage to transform the training DRRs into pCTV images. In the inference stage, the trained CNNs transformed the test XF images into pCTV images, thus identifying target positions and shapes. RESULTS: The visual analysis of DL attention heatmaps for a test image demonstrated that our method focused CNN attention on soft tissue and global image features rather than bones and local features. The processing time for each patient-and-angle-specific dataset in the training stage was ∼30 min, whereas that in the inference stage was 8 ms/frame. The estimated three-dimensional 95 percentile tracking error, Jaccard index, and Hausdorff distance for 10 patients were 1.3-3.9 mm, 0.85-0.94, and 0.6-4.9 mm, respectively. CONCLUSIONS: The proposed attention-based data augmentation with both RO and NI made the CNN behavior more explainable and more controllable. The results obtained demonstrated the feasibility of real-time markerless lung tumor segmentation in kV XF images for IGRT.

Analysis of diaphragm movements to specify geometric uncertainties of respiratory gating near end-exhalation for irradiation fields involving the liver dome.

BACKGROUND AND PURPOSE: The technique of gating near end-exhalation is commonly adopted to reduce respiration-associated geometric uncertainties for particle beam therapy. However, for irradiation fields involving the liver dome, how diaphragm movements generating liver-lung interface change, alongside geometric uncertainties, remain unspecified. METHODS AND MATERIALS: Patients receiving respiratory-gated computed tomography (RGCT) with four-dimensional computed tomography (4DCT) scans during simulation were retrospectively reviewed. Differences (Δ) between RGCT and 4DCT images, including diaphragm displacements and liver-lung interface changes, were investigated to specify geometric uncertainties during early inhalation phases. Craniocaudal displacements (Δy, in sagittal/coronal planes) of diaphragm segments (dorsal/ventral/right lateral/medial), liver area changes (ΔA, in axial planes), and liver extent changes in specific directions of incidence (Δr, in axial planes) were analyzed. RESULTS: Altogether, 162 patients received simulating RGCT and 4DCT scans. In 22 of them, both images involved the liver dome. For most cases during early inhalation phases, the Δy values in the dorsal diaphragm were significantly greater than those in the ventral diaphragm (p < 0.05), the ΔA values were significantly enlarged with inhalation progressing (p < 0.05), and the Δr values in the dorsal direction were significantly larger than those in the ventral direction (p < 0.05). These results suggested that the dorsal diaphragm moves earlier and more in a caudal direction than the ventral diaphragm during early inhalation phases. CONCLUSIONS: For respiratory-gated radiotherapy near end-exhalation and irradiation fields involving the liver dome, components of geometric uncertainties are temporospatial, including diaphragm segment movements, inhalation phases of irradiation, and beam angles of incidence.

Clinical practice vs. state-of-the-art research and future visions: Report on the 4D treatment planning workshop for particle therapy - Edition 2018 and 2019.

The 4D Treatment Planning Workshop for Particle Therapy, a workshop dedicated to the treatment of moving targets with scanned particle beams, started in 2009 and since then has been organized annually. The mission of the workshop is to create an informal ground for clinical medical physicists, medical physics researchers and medical doctors interested in the development of the 4D technology, protocols and their translation into clinical practice. The 10th and 11th editions of the workshop took place in Sapporo, Japan in 2018 and Krakow, Poland in 2019, respectively. This review report from the Sapporo and Krakow workshops is structured in two parts, according to the workshop programs. The first part comprises clinicians and physicists review of the status of 4D clinical implementations. Corresponding talks were given by speakers from five centers around the world: Maastro Clinic (The Netherlands), University Medical Center Groningen (The Netherlands), MD Anderson Cancer Center (United States), University of Pennsylvania (United States) and The Proton Beam Therapy Center of Hokkaido University Hospital (Japan). The second part is dedicated to novelties in 4D research, i.e. motion modelling, artificial intelligence and new technologies which are currently being investigated in the radiotherapy field.

Monitoring patient movement with boron neutron capture therapy and motion capture technology.

In boron neutron capture therapy (BNCT), a patient must remain in a fixed position during the irradiation process. In this study, a system was devised that can guide a patient to the correct position and the patient can be monitored during the irradiation process. This is achieved by using motion capture technology that consists of many cameras. The discrepancy of the measured coordinates for each marker on a phantom by the system was less than 5 mm. For practical applications, further research and verification are required.

Evaluation of Dose Distribution and Normal Tissue Complication Probability of a Combined Dose of Cone-Beam Computed Tomography Imaging with Treatment in Prostate Intensity-Modulated Radiation Therapy.

PURPOSE: The purpose of this study is to evaluate the effects of cone-beam computed tomography (CBCT) on dose distribution and normal tissue complication probability (NTCP) by constructing a comprehensive dose evaluation system for prostate intensity-modulated radiation therapy (IMRT). METHODS: A system that could combine CBCT and treatment doses with MATLAB was constructed. Twenty patients treated with prostate IMRT were studied. A mean dose of 78 Gy was prescribed to the prostate region, excluding the rectal volume from the target volume, with margins of 4 mm to the dorsal side of the prostate and 7 mm to the entire circumference. CBCT and treatment doses were combined, and the dose distribution and the NTCP of the rectum and bladder were evaluated. RESULTS: The radiation dose delivered to 2% and 98% of the target volume increased by 0.90 and 0.74 Gy on average, respectively, in the half-fan mode and on average 0.76 and 0.72 Gy, respectively, in the full-fan mode. The homogeneity index remained constant. The percent volume of the rectum and bladder irradiated at each dose increased slightly, with a maximum increase of <1%. The rectal NTCP increased by approximately 0.07% from 0.46% to 0.53% with the addition of a CBCT dose, while the maximum NTCP in the bladder was approximately 0.02%. CONCLUSIONS: This study demonstrated a method to evaluate a combined dose of CBCT and a treatment dose using the constructed system. The combined dose distribution revealed increases of <1% volume in the rectal and bladder doses and approximately 0.07% in the rectal NTCP.

Reduction of the number of stacking layers in proton uniform scanning.

Uniform scanning with a relatively large beam size can improve beam utilization efficiency more than conventional irradiation methods using scatterers and can achieve a large-field, long-range and large spread-out Bragg peak (SOBP). The SOBP is obtained by energy stacking in uniform scanning, but its disadvantage is that the number of stacking layers is large, especially in the low-energy region, because the Bragg peak of the pristine beam is very sharp. We applied a mini-ridge filter to broaden the pristine Bragg peak up to a stacked layer thickness of 1 or 2 cm in order to decrease the number of stacking layers. The number of stacking layers can be reduced to 20% or less than that in the case of pristine beam stacking. Although the distal falloff of the SOBP is deteriorated by applying the mini-ridge filter, we can improve the distal falloff to that of pristine beam stacking by introducing the distal filter to the irradiation of the most distal layer. Uniform scanning in combination with mini-ridge filter use can more than double the beam utilization efficiency over that of passive irradiation techniques.

Liver phantom design and dosimetric verification in participating institutions for a proton beam therapy in patients with resectable hepatocellular carcinoma: Japan Clinical Oncology Group trial (JCOG1315C).

BACKGROUND AND PURPOSE: In Japan, the first domestic clinical trial of proton beam therapy for the liver was initiated as the Japan Clinical Oncology Group trial (JCOG1315C: Non-randomized controlled study comparing proton beam therapy and hepatectomy for resectable hepatocellular carcinoma). Purposes of this study were to develop a new dosimetric verification system and to carry out a credentialing for the JCOG1315C clinical trial. MATERIALS AND METHODS: Accuracy and differences in doses in proton treatment planning among participating institutions were surveyed and investigated. We designed and developed a suitable water tank-type liver phantom for a dosimetric verification of proton beam therapy for liver. In a visiting survey of five institutions participating in the clinical trial, we performed the dosimetric verification using the liver phantom and an air-filled ionization chamber. RESULTS: The shape of the dose distributions calculated in proton treatment planning was characteristic and dependent on the manufacturers of the proton beam therapy system, the proton treatment planning system and the setup at the participating institutions. Widths of the lateral penumbra were 5.8-12.7 mm among participating institutions. The accuracy between the calculated and the measured doses in the proton irradiation was within 3% at five measurement points including both points on the isocenter and off the isocenter. CONCLUSIONS: These findings confirmed the accuracy of the delivery doses in the institutions participating in the clinical trial, and the clinical trial with integration of all institutions (five institutions) could be initiated.

Measurement of neutron ambient dose equivalent in passive carbon-ion and proton radiotherapies.

Secondary neutron ambient dose equivalents per the treatment absorbed dose in passive carbon-ion and proton radiotherapies were measured using a rem meter, WENDI-II at two carbon-ion radiotherapy facilities and four proton radiotherapy facilities in Japan. Our measured results showed that (1) neutron ambient dose equivalent in carbon-ion radiotherapy is lower than that in proton radiotherapy, and (2) the difference to the measured neutron ambient dose equivalents among the facilities is within a factor of 3 depending on the operational beam setting used at the facility and the arrangement of the beam line, regardless of the method for making a laterally uniform irradiation field: the double scattering method or the single-ring wobbling method. The reoptimization of the beam line in passive particle radiotherapy is an effective way to reduce the risk of secondary cancer because installing an adjustable precollimator and designing the beam line devices with consideration of their material, thickness and location, etc., can significantly reduce the neutron exposure. It was also found that the neutron ambient dose equivalent in passive particle radiotherapy is equal to or less than that in the photon radiotherapy. This result means that not only scanning particle radiotherapy but also passive particle radiotherapy can provide reduced exposure to normal tissues around the target volume without an accompanied increase in total body dose.

Novel real-time tumor-contouring method using deep learning to prevent mistracking in X-ray fluoroscopy.

Robustness to obstacles is the most important factor necessary to achieve accurate tumor tracking without fiducial markers. Some high-density structures, such as bone, are enhanced on X-ray fluoroscopic images, which cause tumor mistracking. Tumor tracking should be performed by controlling "importance recognition": the understanding that soft-tissue is an important tracking feature and bone structure is unimportant. We propose a new real-time tumor-contouring method that uses deep learning with importance recognition control. The novelty of the proposed method is the combination of the devised random overlay method and supervised deep learning to induce the recognition of structures in tumor contouring as important or unimportant. This method can be used for tumor contouring because it uses deep learning to perform image segmentation. Our results from a simulated fluoroscopy model showed accurate tracking of a low-visibility tumor with an error of approximately 1 mm, even if enhanced bone structure acted as an obstacle. A high similarity of approximately 0.95 on the Jaccard index was observed between the segmented and ground truth tumor regions. A short processing time of 25 ms was achieved. The results of this simulated fluoroscopy model support the feasibility of robust real-time tumor contouring with fluoroscopy. Further studies using clinical fluoroscopy are highly anticipated.

Waveform simulation based on 3D dose distribution for acoustic wave generated by proton beam irradiation.

A pulsed proton beam is capable of generating an acoustic wave when it is absorbed by a medium. This phenomenon suggests that the acoustic waveform produced may well include information on the three-dimensional (3D) dose distribution of the proton beam. We simulated acoustic waveforms by using a transmission model based on the Green function and the 3D dose distribution. There was reasonable agreement between the calculated and measured results. The results obtained confirm that the acoustic waveform includes information on the dose distribution.

A comparative study of dose distribution of PBT, 3D-CRT and IMRT for pediatric brain tumors.

INTRODUCTION: It was reported that proton beam therapy (PBT) reduced the normal brain dose compared with X-ray therapy for pediatric brain tumors. We considered whether there was not the condition that PBT was more disadvantageous than intensity modulated photon radiotherapy (IMRT) and 3D conventional radiotherapy (3D-CRT) for treatment of pediatric brain tumors about the dose reduction for the normal brain when the tumor location or tumor size were different. METHODS: The subjects were 12 patients treated with PBT at our institute, including 6 cases of ependymoma treated by local irradiation and 6 cases of germinoma treated by irradiation of all four cerebral ventricles. IMRT and 3D-CRT treatment plans were made for these 12 cases, with optimization using the same planning conditions as those for PBT. Model cases were also compared using sphere targets with different diameters or locations in the brain, and the normal brain doses with PBT, IMRT and 3D-CRT were compared using the same planning conditions. RESULTS: PBT significantly reduced the average dose to normal brain tissue compared to 3D-CRT and IMRT in all cases. There was no difference between 3D-CRT and IMRT. The average normal brain doses for PBT, 3D-CRT, and IMRT were 5.1-34.8% (median 14.9%), 11.0-48.5% (23.8%), and 11.5-53.1% (23.5%), respectively, in ependymoma cases; and 42.3-61.2% (48.9%), 54.5-74.0% (62.8%), and 56.3-72.1% (61.2%), respectively, in germinoma cases. In the model cases, PBT significantly reduced the average normal brain dose for larger tumors and for tumors located at the periphery of the brain. CONCLUSION: PBT reduces the average dose to normal brain tissue, compared with 3D-CRT and IMRT. The effect is higher for a tumor that is larger or located laterally.

Dual ring multilayer ionization chamber and theory-based correction technique for scanning proton therapy.

PURPOSE: To develop a multilayer ionization chamber (MLIC) and a correction technique that suppresses differences between the MLIC and water phantom measurements in order to achieve fast and accurate depth dose measurements in pencil beam scanning proton therapy. METHODS: The authors distinguish between a calibration procedure and an additional correction: 1-the calibration for variations in the air gap thickness and the electrometer gains is addressed without involving measurements in water; 2-the correction is addressed to suppress the difference between depth dose profiles in water and in the MLIC materials due to the nuclear interaction cross sections by a semiempirical model tuned by using measurements in water. In the correction technique, raw MLIC data are obtained for each energy layer and integrated after multiplying them by the correction factor because the correction factor depends on incident energy. The MLIC described here has been designed especially for pencil beam scanning proton therapy. This MLIC is called a dual ring multilayer ionization chamber (DRMLIC). The shape of the electrodes allows the DRMLIC to measure both the percentage depth dose (PDD) and integrated depth dose (IDD) because ionization electrons are collected from inner and outer air gaps independently. RESULTS: IDDs for which the beam energies were 71.6, 120.6, 159, 180.6, and 221.4 MeV were measured and compared with water phantom results. Furthermore, the measured PDDs along the central axis of the proton field with a nominal field size of 10 × 10 cm(2) were compared. The spread out Bragg peak was 20 cm for fields with a range of 30.6 and 3 cm for fields with a range of 6.9 cm. The IDDs measured with the DRMLIC using the correction technique were consistent with those that of the water phantom; except for the beam energy of 71.6 MeV, all of the points satisfied the 1% dose/1 mm distance to agreement criterion of the gamma index. The 71.6 MeV depth dose profile showed slight differences in the shallow region, but 94.5% of the points satisfied the 1%/1 mm criterion. The 90% ranges, defined at the 90% dose position in distal fall off, were in good agreement with those in the water phantom, and the range differences from the water phantom were less than ±0.3 mm. The PDDs measured with the DRMLIC were also consistent with those that of the water phantom; 97% of the points passed the 1%/1 mm criterion. CONCLUSIONS: It was demonstrated that the new correction technique suppresses the difference between the depth dose profiles obtained with the MLIC and those obtained from a water phantom, and a DRMLIC enabling fast measurements of both IDD and PDD was developed. The IDDs and PDDs measured with the DRMLIC and using the correction technique were in good agreement with those that of the water phantom, and it was concluded that the correction technique and DRMLIC are useful for depth dose profile measurements in pencil beam scanning proton therapy.

Development of simple high-precision two-dimensional dose-distribution measurement method for proton beam therapy using imaging plate and EBT3.

Although there are several two-dimensional (2D) dose-distribution measurement methods using proton beam therapy, they all have drawbacks; hence, there is no standard method established worldwide. The purpose of this study was to develop a simple, high-precision 2D distribution measurement method for proton beam therapy that uses an imaging plate and EBT3. First, we expanded the maximum readable dose (saturation dose) in the imaging plate. The method involves (i) the control of the fading phenomenon by an annealing process and (ii) the control of the photostimulated luminescence (PSL) phenomenon using a longpass filter (LPF). In method (i), upon heating at 80 °C, the PSL became 0.485 times the room temperature, and in method (ii), we attenuated the PSL by a factor of 0.245 using an LPF. Thus, by combining methods (i) and (ii), we expanded the saturation dose to 2 Gy. Thus, it was possible to measure the imaging plate and EBT3 in the same dose range. We simultaneously measured the percent depth dose using imaging plate and EBT3. We defined a correction factor to match the measured values-which had a reduced sensitivity because of the linear energy transfer (LET) dependence of the imaging plate and EBT3-with reference data and developed a correction factor function. Subsequently, by defining the relative LET dependence of imaging plate and EBT3 as the relative sensitivity and converting the relationship imaging plate between the relative sensitivity and correction factor into a function, we obtained a sensitivity-correction function. By employing this function, measurements with the same accuracy as the reference data were performed using the imaging plate and EBT3.

Whole-body dose evaluation with an adaptive treatment planning system for boron neutron capture therapy.

Dose evaluation for out-of-field organs during radiotherapy has gained interest in recent years. A team led by University of Tsukuba is currently implementing a project for advancing boron neutron capture therapy (BNCT), along with a radiation treatment planning system (RTPS). In this study, the authors used the RTPS (the 'Tsukuba-Plan') to evaluate the dose to out-of-field organs during BNCT. Computed tomography images of a whole-body phantom were imported into the RTPS, and a voxel model was constructed for the Monte Carlo calculations, which used the Particle and Heavy Ion Transport Code System. The results indicate that the thoracoabdominal organ dose during BNCT for a brain tumour and maxillary sinus tumour was 50-360 and 120-1160 mGy-Eq, respectively. These calculations required ∼29.6 h of computational time. This system can evaluate the out-of-field organ dose for BNCT irradiation during treatment planning with patient-specific irradiation conditions.

Comparison of dose-volume histograms between proton beam and X-ray conformal radiotherapy for locally advanced non-small-cell lung cancer.

The purpose of this study was to compare the parameters of the dose-volume histogram (DVH) between proton beam therapy (PBT) and X-ray conformal radiotherapy (XCRT) for locally advanced non-small-cell lung cancer (NSCLC), according to the tumor conditions. A total of 35 patients having NSCLC treated with PBT were enrolled in this analysis. The numbers of TNM stage and lymph node status were IIB (n = 3), IIIA (n = 15) and IIIB (n = 17), and N0 (n = 2), N1 (n = 4), N2 (n = 17) and N3 (n = 12), respectively. Plans for XCRT were simulated based on the same CT, and the same clinical target volume (CTV) was used based on the actual PBT plan. The treatment dose was 74 Gy-equivalent dose (GyE) for the primary site and 66 GyE for positive lymph nodes. The parameters were then calculated according to the normal lung dose, and the irradiation volumes of the doses (Vx) were compared. We also evaluated the feasibility of both plans according to criteria: V5 ≥ 42%, V20 ≥ 25%, mean lung dose ≥ 20 Gy. The mean normal lung dose and V5 to V50 were significantly lower in PBT than in XCRT. The differences were greater with the more advanced nodal status and with the larger CTV. Furthermore, 45.7% of the X-ray plans were classified as inadequate according to the criteria, whereas 17.1% of the proton plans were considered unsuitable. The number of inadequate X-ray plans increased in cases with advanced nodal stage. This study indicated that some patients who cannot receive photon radiotherapy may be able to be treated using PBT.

Prediction error and required internal margin provided for irregular respiratory movements: a phantom study.

PURPOSE: To estimate the prediction error and required internal margin provided for irregular respiratory movements. MATERIALS AND METHODS: Twenty-eight patterns of irregular movement were prepared using a moving phantom. For irregular cycle movement, a cycle of 2.0-5.0 s was inserted into the baseline movement data (3.5-s cycle, 6-mm amplitude) every four cycles. In addition, a cycle of 2.5-4.5 s was further inserted into one of the irregular data points every four cycles to produce more complicated irregularity. For irregular amplitude movement, an amplitude of 3.0-9.0 mm was inserted into the baseline respiratory movement data. In addition, an amplitude of 4.0-8.0 mm was further inserted into one of the irregular data points every four cycles to produce more complicated irregularity. Images of the moving target were acquired using a real-time position management (RPM) and four-dimensional CT (4DCT) system. The displacement from the baseline image and required margin to compensate for irregular movement were calculated. RESULTS: Amplitude irregularity tended to lose stable placement and need larger margins to compensate for the reduction of image reproducibility than cycle irregularity. There was a large displacement and required margin when the target moved with more complicated irregular amplitude. CONCLUSION: The RPM and 4DCT system has a risk of prediction error, which may result from the complicated amplitude irregularity of respiratory movement.

Comparison of adverse effects of proton and X-ray chemoradiotherapy for esophageal cancer using an adaptive dose-volume histogram analysis.

Cardiopulmonary late toxicity is of concern in concurrent chemoradiotherapy (CCRT) for esophageal cancer. The aim of this study was to examine the benefit of proton beam therapy (PBT) using clinical data and adaptive dose-volume histogram (DVH) analysis. The subjects were 44 patients with esophageal cancer who underwent definitive CCRT using X-rays (n = 19) or protons (n = 25). Experimental recalculation using protons was performed for the patient actually treated with X-rays, and vice versa. Target coverage and dose constraints of normal tissues were conserved. Lung V5-V20, mean lung dose (MLD), and heart V30-V50 were compared for risk organ doses between experimental plans and actual treatment plans. Potential toxicity was estimated using protons in patients actually treated with X-rays, and vice versa. Pulmonary events of Grade ≥2 occurred in 8/44 cases (18%), and cardiac events were seen in 11 cases (25%). Risk organ doses in patients with events of Grade ≥2 were significantly higher than for those with events of Grade ≤1. Risk organ doses were lower in proton plans compared with X-ray plans. All patients suffering toxicity who were treated with X-rays (n = 13) had reduced predicted doses in lung and heart using protons, while doses in all patients treated with protons (n = 24) with toxicity of Grade ≤1 had worsened predicted toxicity with X-rays. Analysis of normal tissue complication probability showed a potential reduction in toxicity by using proton beams. Irradiation dose, volume and adverse effects on the heart and lung can be reduced using protons. Thus, PBT is a promising treatment modality for the management of esophageal cancer.