Dosimetric comparison between proton beam therapy and photon radiation therapy for locally advanced non-small cell lung cancer.

OBJECTIVE: To assess the feasibility of proton beam therapy for the patients with locally advanced non-small lung cancer. METHODS: The dosimetry was analyzed retrospectively to calculate the doses to organs at risk, such as the lung, heart, esophagus and spinal cord. A dosimetric comparison between proton beam therapy and dummy photon radiotherapy (three-dimensional conformal radiotherapy) plans was performed. Dummy intensity-modulated radiotherapy plans were also generated for the patients for whom curative three-dimensional conformal radiotherapy plans could not be generated. RESULTS: Overall, 33 patients with stage III non-small cell lung cancer were treated with proton beam therapy between December 2011 and August 2014. The median age of the eligible patients was 67 years (range: 44-87 years). All the patients were treated with chemotherapy consisting of cisplatin/vinorelbine or carboplatin. The median prescribed dose was 60 GyE (range: 60-66 GyE). The mean normal lung V20 GyE was 23.6% (range: 14.9-32%), and the mean normal lung dose was 11.9 GyE (range: 6.0-19 GyE). The mean esophageal V50 GyE was 25.5% (range: 0.01-63.6%), the mean heart V40 GyE was 13.4% (range: 1.4-29.3%) and the mean maximum spinal cord dose was 40.7 GyE (range: 22.9-48 GyE). Based on dummy three-dimensional conformal radiotherapy planning, 12 patients were regarded as not being suitable for radical thoracic three-dimensional conformal radiotherapy. All the dose parameters of proton beam therapy, except for the esophageal dose, were lower than those for the dummy three-dimensional conformal radiotherapy plans. In comparison to the intensity-modulated radiotherapy plan, proton beam therapy also achieved dose reduction in the normal lung. None of the patients experienced grade 4 or worse non-hematological toxicities. CONCLUSIONS: Proton beam therapy for patients with stage III non-small cell lung cancer was feasible and was superior to three-dimensional conformal radiotherapy for several dosimetric parameters.

Urethral identification using three-dimensional magnetic resonance imaging and interfraction urethral motion evaluation for prostate stereotactic body radiotherapy.

Prostatic urethra identification is crucial in prostate stereotactic body radiotherapy (SBRT) to reduce the risk of urinary toxicity. Although computed tomography (CT) with a catheter is commonly employed, it is invasive, and catheter placement may displace the urethral position, resulting in possible planning inaccuracies. However, magnetic resonance imaging (MRI) can overcome these weaknesses. Accurate urethral identification and minimal daily variation could ensure a highly accurate SBRT. In this study, we investigated the usefulness of a three-dimensional (3D) T2-weighted (T2W) sequence for urethral identification, and the interfractional motion of the prostatic urethra on CT with a catheter and MRI without a catheter for implementing noninvasive SBRT. Thirty-two patients were divided into three groups. The first group underwent MRI without a catheter to evaluate urethral identification by two-dimensional (2D)- and 3D-T2W sequences using mean slice-wise Hausdorff distance (MSHD) and Dice similarity coefficient (DSC) of the contouring by two operators and using visual assessment. The second group provided 3-day MRI data without a catheter using 3D-T2W, and the third provided 3-day CT data with a catheter to evaluate the interfractional motion using MSHD, DSC, and displacement distance (Dd). The MSHD and DSC for the interoperator variability in urethral identification and visual assessment were superior in 3D-T2W than in 2D-T2W. Regarding interfractional motion, the Dd value for prostatic urethra was smaller in MRI than in CT. These findings indicate that the 3D-T2W yielded adequate prostatic urethral identification, and catheter-free MRI resulted in less interfractional motion, suggesting that 3D-T2W MRI without a catheter is a feasible noninvasive approach to performing prostate SBRT.

Patient handling system for carbon ion beam scanning therapy.

Our institution established a new treatment facility for carbon ion beam scanning therapy in 2010. The major advantages of scanning beam treatment compared to the passive beam treatment are the following: high dose conformation with less excessive dose to the normal tissues, no bolus compensator and patient collimator/multi-leaf collimator, better dose efficiency by reducing the number of scatters. The new facility was designed to solve several problems encountered in the existing facility, at which several thousand patients were treated over more than 15 years. Here, we introduce the patient handling system in the new treatment facility. The new facility incorporates three main systems, a scanning irradiation system (S-IR), treatment planning system (TPS), and patient handling system (PTH). The PTH covers a wide range of functions including imaging, geometrical/position accuracy including motion management (immobilization, robotic arm treatment bed), layout of the treatment room, treatment workflow, software, and others. The first clinical trials without respiratory gating have been successfully started. The PTH allows a reduction in patient stay in the treatment room to as few as 7 min. The PTH plays an important role in carbon ion beam scanning therapy at the new institution, particularly in the management of patient handling, application of image-guided therapy, and improvement of treatment workflow, and thereby allows substantially better treatment at minimum cost.

Development of digital reconstructed radiography software at new treatment facility for carbon-ion beam scanning of National Institute of Radiological Sciences.

To increase the accuracy of carbon ion beam scanning therapy, we have developed a graphical user interface-based digitally-reconstructed radiograph (DRR) software system for use in routine clinical practice at our center. The DRR software is used in particular scenarios in the new treatment facility to achieve the same level of geometrical accuracy at the treatment as at the imaging session. DRR calculation is implemented simply as the summation of CT image voxel values along the X-ray projection ray. Since we implemented graphics processing unit-based computation, the DRR images are calculated with a speed sufficient for the particular clinical practice requirements. Since high spatial resolution flat panel detector (FPD) images should be registered to the reference DRR images in patient setup process in any scenarios, the DRR images also needs higher spatial resolution close to that of FPD images. To overcome the limitation of the CT spatial resolution imposed by the CT voxel size, we applied image processing to improve the calculated DRR spatial resolution. The DRR software introduced here enabled patient positioning with sufficient accuracy for the implementation of carbon-ion beam scanning therapy at our center.

The Impact of System-Related Magnetic Resonance Imaging Geometric Distortion in Stereotactic Radiotherapy: A Case Report.

Magnetic resonance imaging (MRI) is now essential in stereotactic radiotherapy (SRT) planning for brain tumors because of its excellence in soft-tissue contrast and high spatial resolution. However, MRI distortion is sometimes difficult to recognize, and it may cause large misalignments in radiotherapy planning. In this case report, we will show how much difference in the dose distribution of SRT can be made by using MRI without distortion correction.

＜Editors' Choice＞ Evaluation of system-related magnetic resonance imaging geometric distortion in radiation therapy treatment planning: two approaches and effectiveness of three-dimensional distortion correction.

We propose two methods to evaluate system-related distortion in magnetic resonance imaging (MRI) in radiation therapy treatment planning (RTP) and demonstrate the importance of three-dimensional (3D) distortion correction (DC) by quantitatively measuring the distortion magnitude. First, a small pin phantom was scanned at multiple positions using an external laser guide for accurate phantom placement and combined into one image encompassing a large area. Direct plane images were used for evaluating in-plane distortion and multiplanar reconstruction images for through-plane distortion with no DC, two-dimensional (2D) DC, and 3D DC. Second, a large grid sheet was scanned as the direct plane of the phantom placement. The distortion magnitude was determined by measuring the displacement between the MRI and reference coordinates. The measured distortions were compared between in- and through-plane when applying DC and between the two methods. The small pin phantom method can be used to evaluate a wide range of distortions, whereas data from the entire plane can be obtained with a single scan using the grid sheet without a laser guide. The mean distortion magnitudes differed between the methods. Furthermore, the 3D DC reduced in- and through-plane distortions. In conclusion, the small pin phantom method can be used to evaluate a wide range of distortions by creating a combined image, whereas the grid sheet method is simpler, accurate, repeatable, and does not require a special-order phantom or laser guide. As 3D DC reduces both in- and through-plane distortions, it can be used to improve RTP quality.

Effectiveness of Porous Glass Membrane Pumping Emulsification Device in Transarterial Chemoembolization for Solitary Hepatocellular Carcinoma.

BACKGROUND/AIM: A porous glass membrane-pumping emulsification device (GMD) enables the formation of a high-percentage water-in-oil emulsion with homogeneous and stable droplets. Although GMD is expected to improve the locoregional therapeutic effects of transarterial chemoembolization (TACE) in hepatocellular carcinoma (HCC), its effectiveness in the management of solitary HCC remains unclear. PATIENTS AND METHODS: Patients treated for solitary HCCs (<5 cm) were retrospectively reviewed. A total of 46 patients who could not undergo liver resection and were unsuitable for radiofrequency ablation were included in this study. Among these, 22 patients underwent TACE using a GMD (GMD-TACE group) and 24 underwent stereotactic body radiotherapy (SBRT) using a robotic radiosurgery system (SBRT group). Local control rates were compared between the two groups. RESULTS: The median HCC tumour size was 24 mm (range=12-50 mm) and 22 mm (range=8-39 mm) in the GMD-TACE and SBRT groups, respectively; however, the difference between the groups was not significant. Age, liver function test results, or Child-Pugh scores were not significantly different between the two groups. The rate of local control at 6 months after treatment was 100% in both groups. Although the 1-year local control rate was higher in the SBRT group (92.3%) than in the GMD-TACE group (81.8%), there was no significant difference in the log-rank test (p=0.654). No major treatment-related complications occurred in either group during the observation period. CONCLUSION: TACE with GMD could be considered an effective treatment option for the management of solitary HCC.

Hybrid 3D T1-weighted gradient-echo sequence for fiducial marker detection and tumor delineation via magnetic resonance imaging in liver stereotactic body radiation therapy.

PURPOSE: Gold fiducial markers are used to guide liver stereotactic body radiation therapy (SBRT) and are hard to detect by magnetic resonance imaging (MRI). In this study, the parameters of the three-dimensional T1-weighted turbo gradient-echo (3D T1W-GRE) sequence were optimized for gold marker detection without degrading tumor delineation. METHODS: Custom-made phantoms mimicking tumor and normal liver parenchyma were prepared and embedded with a gold marker. The 3D T1W-GRE was scanned by varying echo time (TE), bandwidth (BW), flip angle (FA), and base matrix size. The signal-to-noise ratio (SNR), contrast ratio (CR), and relative standard deviation (RSD) of the signal intensity in the area including the gold marker were evaluated, and the parameters were optimized accordingly. The modified 3D T1W-GRE (called HYBRID) was compared with the conventional T1W-GRE- and T2*-sequences in both phantom and clinical studies. In the clinical study of six patients with primary liver tumors, two observers visually assessed marker detection, tumor delineation, and overall image quality on a four-point scale. RESULTS: In the phantom study, HYBRID showed significantly higher SNR and RSD than those of conventional T1W-GRE (P < 0.001). In the clinical study, HYBRID yielded significantly higher scores than conventional T1W-GRE did in terms of marker detection (P < 0.001). The scores of both sequences were not statistically different in terms of tumor delineation and overall image quality (P = 0.56 and P = 0.32). CONCLUSIONS: The proposed HYBRID sequence improved gold fiducial marker detection without degrading tumor delineation in MRI for SBRT of primary liver tumor.

Dosimetric variation due to CT inter-slice spacing in four-dimensional carbon beam lung therapy.

When CT data with thick slice thickness are used in treatment planning, geometrical uncertainty may induce dosimetric errors. We evaluated carbon ion dose variations due to different CT slice thicknesses using a four-dimensional (4D) carbon ion beam dose calculation, and compared results between ungated and gated respiratory strategies. Seven lung patients were scanned in 4D mode with a 0.5 mm slice thickness using a 256-multi-slice CT scanner. CT images were averaged with various numbers of images to simulate reconstructed images with various slice thicknesses (0.5-5.0 mm). Two scenarios were studied (respiratory-ungated and -gated strategies). Range compensators were designed for each of the CT volumes with coarse inter-slice spacing to cover the internal target volume (ITV), as defined from 4DCT. Carbon ion dose distribution was computed for each resulting ITV on the 0.5 mm slice 4DCT data. The accumulated dose distribution was then calculated using deformable registration for 4D dose assessment. The magnitude of over- and under-dosage was found to be larger with the use of range compensators designed with a coarser inter-slice spacing than those obtained with a 0.5 mm slice thickness. Although no under-dosage was observed within the clinical target volume (CTV) region, D95 remained at over 97% of the prescribed dose for the ungated strategy and 95% for the gated strategy for all slice thicknesses. An inter-slice spacing of less than 3 mm may be able to minimize dose variation between the ungated and gated strategies. Although volumes with increased inter-slice spacing may reduce geometrical accuracy at a certain respiratory phase, this does not significantly affect delivery of the accumulated dose to the target during the treatment course.

Magnitude of residual internal anatomy motion on heavy charged particle dose distribution in respiratory gated lung therapy.

PURPOSE: To assess the variation in carbon beam dose distribution due to residual motion in lung cancer patients undergoing respiratory-gated radiotherapy. METHODS AND MATERIALS: A total of 11 lung cancer patients underwent four-dimensional computed tomography with a 256-multislice computed tomography scanner under free-breathing conditions. A compensating bolus was designed to cover the treatment beam for all planning target volumes during a 30% duty cycle centered on exhalation (gating window). This bolus was applied to the four-dimensional computed tomography data for one respiratory cycle, and then the carbon beam dose distribution was calculated. RESULTS: A water equivalent pathlength variation of <5 mm was observed in the gating window, but this increased to 95% volume irradiation is dependent on the respiratory phase but not the gating window. However, the dose for >95% volume irradiation correlated well with the tumor displacement distance. More than 90% of the dose for >95% volume irradiation could be delivered in the gating window with <4-mm tumor displacement resulting from exhalation. CONCLUSION: The results of our study have shown that even when the treatment beam delivery occurs outside the gating window, the prescribed dose to the target is not affected in patients with a tumor displacement of <4 mm. Thus, respiratory gating is not required in radiotherapy for patients with <4-mm tumor displacement in a respiratory cycle.

Effect of patient positioning on carbon-ion therapy planned dose distribution to pancreatic tumors and organs at risk.

PURPOSE: Pancreatic tumor treatment dose distribution variations associated with supine and prone patient positioning were evaluated. METHODS: A total of 33 patients with pancreatic tumors who underwent CT in the supine and prone positions were analyzed retrospectively. Gross tumor volume (GTV), planning target volume (PTV), and organs at risk (OARs) (duodenum and stomach) were contoured. The prescribed dose of 55.2Gy (RBE) was planned from four beam angles (0°, 90°, 180°, and 270°). Patient collimator and compensating boli were designed for each field. Dose distributions were calculated for each field in the supine and prone positions. To improve dose distribution, patient positioning was selected from supine or prone for each beam field. RESULTS: Compared with conventional beam angle and patient positioning, D2cc of 1st-2nd portion of duodenum (D1-D2), 3rd-4th portion of duodenum (D3-D4), and stomach could be reduced to a maximum of 6.4Gy (RBE), 3.5Gy (RBE), and 4.5Gy (RBE) by selection of patient positioning. V10 of D1-D2, D3-D4, and stomach could be reduced to a maximum of 7.2cc, 11.3cc, and 11.5cc, respectively. D95 of GTV and PTV were improved to a maximum of 6.9% and 3.7% of the prescribed dose, respectively. CONCLUSIONS: Optimization of patient positioning for each beam angle in treatment planning has the potential to reduce OARs dose maintaining tumor dose in pancreatic treatment.

Movement of a small tumour in contact with the diaphragm: characterisation with four-dimensional CT.

Radiotherapy to the thoracic and abdominal regions can require tailoring of the planning target volume (PTV) to compensate for respiratory motion. We evaluated dose variations that might occur to a small target close to the diaphragm. We compared tumour and diaphragm displacement in gated and non-gated four-dimensional computed tomography (CT) of a patient with a peridiaphragmatic lesion, using peak exhalation as a baseline. Diaphragmatic motion was 12.7 mm in the inferior direction. The tumour was noted to move 1.0 mm to the right, 1.1 mm anteriorly, and 1.4 mm superiorly. The tumour moved in the opposite direction from the diaphragm in the vertical axis. This paradoxical motion did not affect the dose distribution because the beam did not irradiate the liver on non-gated treatment plans, and remained within the PTV. We observed minimal movement of a small tumour on 4D CT, in spite of it being in contact with, and moving opposite to, the diaphragm. In this patient, respiratory gating during irradiation was not needed, making it possible to reduce the treatment time.

Dosimetric impact of 4DCT artifact in carbon-ion scanning beam treatment: Worst case analysis in lung and liver treatments.

INTRODUCTION: We evaluated the impact of 4DCT artifacts on carbon-ion pencil beam scanning dose distributions in lung and liver treatment. METHODS & MATERIALS: 4DCT was performed in 20 liver and lung patients using area-detector CT (original 4DCT). 4DCT acquisition by multi-detector row CT was simulated using original 4DCT by selecting other phases randomly (plus/minus 20% phases). Since tumor position can move over the respiratory range in original 4DCT, mid-exhalation was set as reference phase. Total prescribed dose of 60Gy (RBE) was delivered to the clinical target volume (CTV). Reference dose distribution was calculated with the original CT, and actual dose distributions were calculated with treatment planning parameters optimized using the simulated CT (simulated dose). Dose distribution was calculated by substituting these parameters into the original CT. RESULTS: For liver cases, CTV-D95 and CTV-Dmin values for the reference dose were 97.6±0.5% and 89.8±0.6% of prescribed dose, respectively. Values for the simulated dose were significantly degraded, to 88.6±14.0% and 46.3±26.7%, respectively. Dose assessment results for lung cases were 84.8±12.8% and 58.0±24.5% for the simulated dose, showing significant degradation over the reference dose of 95.1±1.5% and 87.0±2.2%, respectively. CONCLUSIONS: 4DCT image quality should be closely checked to minimize degradation of dose conformation due to 4DCT artifacts. Medical staff should pay particular attention to checking the quality of 4DCT images as a function of respiratory phase, because it is difficult to recognize 4DCT artifact on a single phase in some cases.

Four-dimensional layer-stacking carbon-ion beam dose distribution by use of a lung numeric phantom.

To extend layer-stacking irradiation to accommodate intrafractional organ motion, we evaluated the carbon-ion layer-stacking dose distribution using a numeric lung phantom. We designed several types of range compensators. The planning target volume was calculated from the respective respiratory phases for consideration of intrafractional beam range variation. The accumulated dose distribution was calculated by registering of the dose distributions at respective phases to that at the reference phase. We evaluated the dose distribution based on the following six parameters: motion displacement, direction, gating window, respiratory cycle, range-shifter change time, and prescribed dose. All parameters affected the dose conformation to the moving target. By shortening of the gating window, dose metrics for superior-inferior (SI) and anterior-posterior (AP) motions were decreased from a D95 of 94 %, Dmax of 108 %, and homogeneity index (HI) of 23 % at T00-T90, to a D95 of 93 %, Dmax of 102 %, and HI of 20 % at T40-T60. In contrast, all dose metrics except the HI were independent of respiratory cycle. All dose metrics in SI motion were almost the same in respective motion displacement, with a D95 of 94 %, Dmax of 108 %, Dmin of 89 %, and HI of 23 % for the ungated phase, and D95 of 93 %, Dmax of 102 %, Dmin of 85 %, and HI of 20 % for the gated phase. The dose conformation to a moving target was improved by the gating strategy and by an increase in the prescribed dose. A combination of these approaches is a practical means of adding them to existing treatment protocols without modifications.

Development of fast patient position verification software using 2D-3D image registration and its clinical experience.

To improve treatment workflow, we developed a graphic processing unit (GPU)-based patient positional verification software application and integrated it into carbon-ion scanning beam treatment. Here, we evaluated the basic performance of the software. The algorithm provides 2D/3D registration matching using CT and orthogonal X-ray flat panel detector (FPD) images. The participants were 53 patients with tumors of the head and neck, prostate or lung receiving carbon-ion beam treatment. 2D/3D-ITchi-Gime (ITG) calculation accuracy was evaluated in terms of computation time and registration accuracy. Registration calculation was determined using the similarity measurement metrics gradient difference (GD), normalized mutual information (NMI), zero-mean normalized cross-correlation (ZNCC), and their combination. Registration accuracy was dependent on the particular metric used. Representative examples were determined to have target registration error (TRE) = 0.45 ± 0.23 mm and angular error (AE) = 0.35 ± 0.18° with ZNCC + GD for a head and neck tumor; TRE = 0.12 ± 0.07 mm and AE = 0.16 ± 0.07° with ZNCC for a pelvic tumor; and TRE = 1.19 ± 0.78 mm and AE = 0.83 ± 0.61° with ZNCC for lung tumor. Calculation time was less than 7.26 s.The new registration software has been successfully installed and implemented in our treatment process. We expect that it will improve both treatment workflow and treatment accuracy.

Evaluation of the dose variation for prostate heavy charged particle therapy using four-dimensional computed tomography.

We quantified dose variation effects due to respiratory-induced intrafractional motion in conventional carbon-ion prostate treatment by using four-dimensional computed tomography (4DCT). 4DCT scans of 20 patients were acquired under free-breathing conditions using a 256 multi-slice CT scanner. The clinical target volume (CTV) was defined as the prostate and the seminal vesicle. Two types of planning target volumes (PTVs) were defined to minimize excessive dose to the rectum. The first PTV (= PTV1) was calculated by adding a 3D uniform margin to the CTV. The second PTV (= PTV2) was cut in a straight line from the top surface of the rectum from PTV1. Compensating boli were designed for the respective PTVs at the peak-exhalation phase, and carbon-ion dose distributions for a single respiratory cycle were calculated using these boli. Dose conformation to prostate, CTV, PTV1 and PTV2 were unchanged for all respiratory phases. The dose for >95% volume irradiation (D95) was 97.7% for prostate, 92.5% for CTV, 74.1% for PTV1 and 96.1% for PTV2 averaged over all patients. The rectum volume at inhalation phase receiving ≤50% of the prescribed dose was smaller than the planning dose due to the abdominal thickness variation. The target dose is not affected by intrafractional respiration in carbon-ion prostate treatment. Small dose variations, however, were observed due to respiratory-induced abdominal thickness variation; therefore the geometrical changes should be considered for prostate particle therapy.

Effective and organ doses using helical 4DCT for thoracic and abdominal therapies.

The capacity of 4DCT to quantify organ motion is beyond conventional 3DCT capability. Local control could be improved. However we are unaware of any reports of organ dose measurements for helical 4DCT imaging. We therefore quantified the radiation doses for helical 4DCT imaging. Organ and tissue dose was measured for thoracic and abdominal 4DCT in helical mode using an adult anthropomorphic phantom. Radiation doses were measured with thermoluminescence dosimeter chips inserted at various anatomical sites on the phantom. For the helical thoracic 4DCT, organ doses were 57.2 mGy for the lung, 76.7 mGy for the thyroids, 48.1 mGy for the breasts, and 10.86 mGy for the colon. The effective doses for male and female phantoms were very similar, with a mean value of 33.1 mSv. For abdominal 4DCT imaging, organ doses were 14.4 mGy for the lung, 0.78 mGy for the thyroids, 9.83 mGy for breasts, and 58.2 mGy for the colon (all obtained by using ICRP 103). We quantified the radiation exposure for thoracic and abdominal helical 4DCT. The doses for helical 4DCT were approximately 1.5 times higher than those for cine 4DCT, however the stepwise image artifact was reduced. 4DCT imaging should be performed with care in order to minimize radiation exposure, but the advantages of 4DCT imaging mandates its incorporation into routine treatment protocols.

Positional dependence of the CT number with use of a cone-beam CT scanner for an electron density phantom in particle beam therapy.

We evaluated the CT number accuracy in determining a CT calibration method for treatment planning by use of a 256 multi-slice CT (MSCT) scanner. An electron density phantom, which extends full length in the longitudinal direction, was scanned by the 256 MSCT scanner in a single rotation. We inserted four types of samples (air, 100 % ethanol, 40 wt% aqueous K(2)HPO(4), and water) into the phantom. The regions of interest were set for all image slices, and the average CT number was calculated in the transverse and longitudinal sections. For the transverse image direction, the CT number became lower toward the center of the phantom with almost all samples. The causes of these phenomena might be attributed to the effects of scattered radiation and those of beam hardening due to the high-atomic-number material (40 wt% aqueous K(2)HPO(4)). However, the phenomena were too complicated to allow us to determine their causes only from the present studies. Meanwhile, for increasing the accuracy of the CT number calibration, a single sample should be inserted, and this step should be repeated with different samples. For the longitudinal direction, the CT number for a 40 wt % aqueous K(2)HPO(4) sample increased by 30 HU from the anode to the cathode side due to variations in the X-ray energy caused by the heel effect. The caveat is that the CT number varies in the longitudinal direction when a CT scanner with a wide beam width is used.

First clinical experience in carbon ion scanning beam therapy: retrospective analysis of patient positional accuracy.

Our institute has constructed a new treatment facility for carbon ion scanning beam therapy. The first clinical trials were successfully completed at the end of November 2011. To evaluate patient setup accuracy, positional errors between the reference Computed Tomography (CT) scan and final patient setup images were calculated using 2D-3D registration software. Eleven patients with tumors of the head and neck, prostate and pelvis receiving carbon ion scanning beam treatment participated. The patient setup process takes orthogonal X-ray flat panel detector (FPD) images and the therapists adjust the patient table position in six degrees of freedom to register the reference position by manual or auto- (or both) registration functions. We calculated residual positional errors with the 2D-3D auto-registration function using the final patient setup orthogonal FPD images and treatment planning CT data. Residual error averaged over all patients in each fraction decreased from the initial to the last treatment fraction [1.09 mm/0.76° (averaged in the 1st and 2nd fractions) to 0.77 mm/0.61° (averaged in the 15th and 16th fractions)]. 2D-3D registration calculation time was 8.0 s on average throughout the treatment course. Residual errors in translation and rotation averaged over all patients as a function of date decreased with the passage of time (1.6 mm/1.2° in May 2011 to 0.4 mm/0.2° in December 2011). This retrospective residual positional error analysis shows that the accuracy of patient setup during the first clinical trials of carbon ion beam scanning therapy was good and improved with increasing therapist experience.

Four-dimensional lung treatment planning in layer-stacking carbon ion beam treatment: comparison of layer-stacking and conventional ungated/gated irradiation.

PURPOSE: We compared four-dimensional (4D) layer-stacking and conventional carbon ion beam distribution in the treatment of lung cancer between ungated and gated respiratory strategies using 4DCT data sets. METHODS AND MATERIALS: Twenty lung patients underwent 4DCT imaging under free-breathing conditions. Using planning target volumes (PTVs) at respective respiratory phases, two types of compensating bolus were designed, a full single respiratory cycle for the ungated strategy and an approximately 30% duty cycle for the exhalation-gated strategy. Beams were delivered to the PTVs for the ungated and gated strategies, PTV(ungated) and PTV(gated), respectively, which were calculated by combining the respective PTV(Tn)s by layer-stacking and conventional irradiation. Carbon ion beam dose distribution was calculated as a function of respiratory phase by applying a compensating bolus to 4DCT. Accumulated dose distributions were calculated by applying deformable registration. RESULTS: With the ungated strategy, accumulated dose distributions were satisfactorily provided to the PTV, with D95 values for layer-stacking and conventional irradiation of 94.0% and 96.2%, respectively. V20 for the lung and Dmax for the spinal cord were lower with layer-stacking than with conventional irradiation, whereas Dmax for the skin (14.1 GyE) was significantly lower (21.9 GyE). In addition, dose conformation to the GTV/PTV with layer-stacking irradiation was better with the gated than with the ungated strategy. CONCLUSIONS: Gated layer-stacking irradiation allows the delivery of a carbon ion beam to a moving target without significant degradation of dose conformity or the development of hot spots.