The purpose of this study was to evaluate intrafraction prostate motion in patients treated with proton therapy and an endorectal balloon or a hydrogel spacer using orthogonal x‐rays acquired before and after each treatment field. This study evaluated 10 patients (662 fields throughout treatment) treated daily with an endorectal balloon (ERB) and 16 patients (840 fields throughout treatment) treated with a hydrogel spacer (GEL) without an ERB. Patient shifts were recorded before and after each treatment field, correlated with a treatment time, using x‐ray imaging and implanted fiducial alignment. For each shift, recorded in X, Y, and Z, a 3D vector was calculated to determine the positional change. There was a statistically significant difference in the mean vector shift between ERB (0.06 cm) and GEL (0.09 cm), (P < 0.001). The mean includes a large number of zero shifts, but the smallest non‐zero shift recorded was 0.2 cm. The largest shifts were, on average, in the Z direction (anterior to posterior). The average Z shift was +0.02 cm for both ERB and GEL. There was no statistical difference between ERB and GEL for shifts greater than 0.3 cm (P = 0.13) or greater than 0.5 cm (P = 0.36). For treatment times between 5 and 9 min, a majority of shifts were less than 0.2 cm, 85.9% for ERB and 73.2% for GEL. There was a significant positive correlation between the vector shifts and field time for both ERB (r = 0.2, P < 0.001) and GEL (r = 0.07, P < 0.04). We have shown that prostate motion is clinically comparable between an ERB and a hydrogel spacer, and the time dependencies are similar. A large majority of shifts for both ERB and hydrogel are well within a typical robust planning margin. For GEL patients, we chose to maintain slightly larger planning margins than for ERB due to already improved rectal sparing with GEL.
In this study, we investigated computationally and experimentally a hexagonal-pattern array of spatially fractionated proton minibeams produced by proton pencil beam scanning (PBS) technique. Spatial fractionation of dose delivery with millimeter or submillimeter beam size has proven to be a promising approach to significantly increase the normal tissue tolerance. Our goals are to obtain an optimized minibeam design and to show that it is feasible to implement the optimized minibeams at the existing proton clinics. Methods: An optimized minibeam arrangement is one that would produce high peak-to-valley dose ratios (PVDRs) in normal tissues and a PVDR approaching unity at the Bragg peak. Using Monte Carlo (MC) code TOPAS we simulated proton pencil beams that mimic those available at the existing proton therapy facilities and obtained a hexagonal-pattern array of minibeams by collimating the proton pencil beams through the 1-3 mm diameter pinholes of a collimator. We optimized the minibeam design by considering different combinations of parameters including collimator material and thickness (t), center-to-center (c-t-c) distance, and beam size. The optimized minibeam design was then evaluated for normal tissue sparing against the uniform pencil beam scanning (PBS) by calculating the therapeutic advantage (TA) in terms of cell survival fraction. Verification measurements using radiochromic films were performed at the Emory proton therapy center (EPTC). Results: Optimized hexagonal-pattern minibeams having PVDRs of >10 at phantom surface and of >3 at depths up to 6 cm were achieved with 2 mm diameter modulated proton minibeams (with proton energies between 120 and 140 MeV) corresponding to a spread-out-Bragg-peak (SOBP) over the depth of 10-14 cm. The results of the film measurements agree with the MC results within 10%. The TA of the 2 mm minibeams against the uniform PBS is >3 from phantom surface to the depth of 5 cm and then smoothly drops to~1.5 as it approaches the proximal edge of the SOBP. For 2 mm minibeams and 6 mm c-t-c distance, we delivered 1.72 Gy at SOBP for 7.2 9 7.2 9 4 cm 3 volume in 48 s. Conclusions: We conclude that it is feasible to implement the optimized hexagonal-pattern 2 mm proton minibeam radiotherapy at the existing proton clinics, because desirable PVDRs and TAs are achievable and the treatment time is reasonable.
BackgroundAlthough there are some controversies regarding whole pelvic radiation therapy (WPRT) due to its gastrointestinal and hematologic toxicities, it is considered for patients with gynecological, rectal, and prostate cancer. To effectively spare organs-at-risk (OAR) doses using multi-leaf collimator (MLC)’s optimal segments, potential dosimetric benefits in volumetric modulated arc therapy (VMAT) using a half-beam technique (HF) were investigated for WPRT.MethodsWhile the size of a fully opened field (FF) was decided to entirely include a planning target volume in all beam’s eye view across arc angles, the HF was designed to use half the FF from the isocenter for dose optimization. The left or the right half of the FF was alternatively opened in VMAT-HF using a pair of arcs rotating clockwise and counterclockwise. Dosimetric benefits of VMAT-HF, presented with dose conformity, homogeneity, and dose–volume parameters in terms of modulation complex score, were compared to VMAT optimized using the FF (VMAT-FF). Consequent normal tissue complication probability (NTCP) by reducing the irradiated volumes was evaluated as well as dose–volume parameters with statistical analysis for OAR. Moreover, beam-on time and MLC position precision were analyzed with log files to assess plan deliverability and clinical applicability of VMAT-HF as compared to VMAT-FF.ResultsWhile VMAT-HF used 60%–70% less intensity modulation complexity than VMAT-FF, it showed superior dose conformity. The small intestine and colon in VMAT-HF showed a noticeable reduction in the irradiated volumes of up to 35% and 15%, respectively, at an intermediate dose of 20–45 Gy. The small intestine showed statistically significant dose sparing at the volumes that received a dose from 15 to 45 Gy. Such a dose reduction for the small intestine and colon in VMAT-HF presented a significant NTCP reduction from that in VMAT-FF. Without sacrificing the beam delivery efficiency, VMAT-HF achieved effective OAR dose reduction in dose–volume histograms.ConclusionsVMAT-HF led to deliver conformal doses with effective gastrointestinal-OAR dose sparing despite using less modulation complexity. The dose of VMAT-HF was delivered with the same beam-on time with VMAT-FF but precise MLC leaf motions. The VMAT-HF potentially can play a valuable role in reducing OAR toxicities associated with WPRT.
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