The purpose of this study was to analyze factors affecting proton stopping-power-ratio (SPR) estimations and range uncertainties in proton therapy planning using the standard stoichiometric calibration. The SPR uncertainties were grouped into five categories according to their origins and then estimated based on previously published reports or measurements. For the first time, the impact of tissue composition variations on SPR estimation was assessed and the uncertainty estimates of each category were determined for low-density (lung), soft, and high-density (bone) tissues. A composite, 95th percentile water-equivalent-thickness uncertainty was calculated from multiple beam directions in 15 patients with various types of cancer undergoing proton therapy. The SPR uncertainties (1σ) were quite different (ranging from 1.6% to 5.0%) in different tissue groups, although the final combined uncertainty (95th percentile) for different treatment sites was fairly consistent at 3.0–3.4%, primarily because soft tissue is the dominant tissue type in human body. The dominant contributing factor for uncertainties in soft tissues was the degeneracy of Hounsfield Numbers in the presence of tissue composition variations. To reduce the overall uncertainties in SPR estimation, the use of dual-energy computed tomography is suggested. The values recommended in this study based on typical treatment sites and a small group of patients roughly agree with the commonly referenced value (3.5%) used for margin design. By using tissue-specific range uncertainties, one could estimate the beam-specific range margin by accounting for different types and amounts of tissues along a beam, which may allow for customization of range uncertainty for each beam direction.

We discovered an empirical relationship between the logarithm of mean excitation energy (ln Im) and the effective atomic number (EAN) of human tissues, which allows for computing patient-specific proton stopping power ratios (SPRs) using dual-energy CT (DECT) imaging. The accuracy of the DECT method was evaluated for 'standard' human tissues as well as their variance. The DECT method was compared to the existing standard clinical practice-a procedure introduced by Schneider et al at the Paul Scherrer Institute (the stoichiometric calibration method). In this simulation study, SPRs were derived from calculated CT numbers of known material compositions, rather than from measurement. For standard human tissues, both methods achieved good accuracy with the root-mean-square (RMS) error well below 1%. For human tissues with small perturbations from standard human tissue compositions, the DECT method was shown to be less sensitive than the stoichiometric calibration method. The RMS error remained below 1% for most cases using the DECT method, which implies that the DECT method might be more suitable for measuring patient-specific tissue compositions to improve the accuracy of treatment planning for charged particle therapy. In this study, the effects of CT imaging artifacts due to the beam hardening effect, scatter, noise, patient movement, etc were not analyzed. The true potential of the DECT method achieved in theoretical conditions may not be fully achievable in clinical settings. Further research and development may be needed to take advantage of the DECT method to characterize individual human tissues.

The dosimetric parameters of the discrete spot scanning proton beam have been measured as part of the clinical commissioning program, and the machine is found to function in a safe manner, making it suitable for patient treatment.

Pencil-beam scanning (PBS) proton therapy (PT), particularly intensity modulated PT, represents the latest advanced PT technology for treating cancers, including thoracic malignancies. On the basis of virtual clinical studies, PBS-PT appears to have great potential in its ability to tightly tailor the dose to the target while sparing critical structures, thereby reducing treatment-related toxicities, particularly for tumors in areas with complicated anatomy. However, implementing PBS-PT for moving targets has several additional technical challenges compared with intensity modulated photon radiation therapy or passive scattering PT. Four-dimensional computed tomography-based motion management and robust optimization and evaluation are crucial for minimizing uncertainties associated with beam range and organ motion. Rigorous quality assurance is required to validate dose delivery both before and during the course of treatment. Active motion management (eg, breath hold), beam gating, rescanning, tracking, or adaptive planning may be needed for cases involving significant motion or changes in motion or anatomy over the course of treatment.