Treating moving targets using a scanning gantry for proton therapy is a promising but very challenging, not yet clinically demonstrated treatment modality. The interference of organ motion with the sequence of the beam delivery produces uncontrolled dose inhomogeneities within the target. One promising approach to overcome this difficulty is to increase the speed of scanning in order to apply the dose repeatedly (so-called repainting). To obtain sufficiently high scanning speeds a new, technologically improved gantry-Gantry 2-has been designed and is currently under construction at PSI. As there are many possible repainting strategies, the way repainting will be implemented on Gantry 2 will depend on the result of a careful analysis of the various treatment delivery strategies available. To achieve this aim, and prior to the start of experimental work with Gantry 2, simulations of dose distribution errors due to organ motion under various beam delivery strategies were investigated. The effects of motion on the dose distribution were studied for moderate motion amplitudes (5 mm) for spherical target volumes in a homogeneous medium and with homogeneous dose. In total over 200,000 dose distributions have been simulated and analyzed and selected results are discussed. From the obtained results we are confident to be able to treat moderately moving targets on Gantry 2 using repainted pencil-beam spot scanning. Continuous line scanning seems to be the most elegant solution; it provides higher repainting rates and produces superior results but is probably more difficult to realize. For larger motion amplitudes, continuous line scanning still shows good results, but we plan anyways to use a gating system for these cases, not only to reduce the inhomogeneity within the target volume but also to reduce safety margins.

In this paper we report on the main design features, on the realization process and on selected first results of the initial commissioning of the new Gantry 2 of PSI for the delivery of proton therapy with new advanced pencil beam scanning techniques. We present briefly the characteristics of the new gantry system with main emphasis on the beam optics, on the characterization of the pencil beam used for scanning and on the performance of the scanning system. The idea is to give an overview of the major components of the whole system. The main long-term technical goal of the new equipment of Gantry 2 is to expand the use of pencil beam scanning to the whole spectrum of clinical indications including moving targets. We report here on the initial experience and problems encountered in the development of the system with selected preliminary results of the ongoing commissioning of Gantry 2. 2 The development framework: the PSI proton therapy facility and its history PSI has a long tradition in using particle beams for cancer treatments.

The potential of tumour tracking for active spot-scanned proton therapy was assessed. Using a 4D-dose calculation and simulated target motion, a tumour tracking algorithm has been implemented and applied to a simple target volume in both homogenous and heterogeneous in silico phantoms. For tracking and retracking (a hybrid solution combining tumour tracking and rescanning), three tracking modes were analysed: 'no tracking' (uncorrected irradiation of a moving target), 'perfect tracking' (no time delays and exact knowledge of target position) and 'imperfect tracking' (simulated time delays or position prediction errors). For all plans, dose homogeneity in the target volume was assessed as the difference between D5 and D95 in the CTV. For the homogeneous phantom, perfect tracking could retrieve nominal dose homogeneity for all motion phases and amplitudes while severe deterioration of treatment outcomes was found for imperfect tracking. The use of retracking reduced the sensitivity to position errors significantly in the homogeneous phantom. In the heterogeneous phantoms (simulated rib proximal to target), the nominal dose homogeneity could not be obtained with perfect tracking. Adjustments in pencil beam positions could cause pencil beams to deform under the influence of the bone, resulting in loss of dose homogeneity. As retracking was not capable of reducing these effects, rescanning provided the best treatment outcomes for moving heterogeneous targets in this study.

PCRL requires a longer treatment time than PCRV for high numbers of rescannings in the NIRS scanning system but is more robust. Although four or more rescans provided good dose homogeneity and conformity, the authors prefer to use more rescannings for clinical cases to further minimize dose degradation effects due to organ motion.