Combined proton–photon therapy for non‐small cell lung cancer

Abstract

Purpose Advanced non‐small cell lung cancer (NSCLC) is still a challenging indication for conventional photon radiotherapy. Proton therapy has the potential to improve outcomes, but proton treatment slots remain a limited resource despite an increasing number of proton therapy facilities. This work investigates the potential benefits of optimally combined proton–photon therapy delivered using a fixed horizontal proton beam line in combination with a photon Linac, which could increase accessibility to proton therapy for such a patient cohort. Materials and methods A treatment planning study has been conducted on a patient cohort of seven advanced NSCLC patients. Each patient had a planning computed tomography scan (CT) and multiple repeated CTs from three different days and for different breath‐holds on each day. Treatment plans for combined proton–photon therapy (CPPT) were calculated for individual patients by optimizing the combined cumulative dose on the initial planning CT only (non‐adapted) as well as on each daily CT respectively (adapted). The impact of inter‐fractional changes and/or breath‐hold variability was then assessed on the repeat breath‐hold CTs. Results were compared to plans for IMRT or IMPT alone, as well as against combined treatments assuming a proton gantry. Plan quality was assessed in terms of dosimetric, robustness and NTCP metrics. Results Combined treatment plans improved plan quality compared to IMRT treatments, especially in regard to reductions of low and medium doses to organs at risk (OARs), which translated into lower NTCP estimates for three side effects. For most patients, combined treatments achieved results close to IMPT‐only plans. Inter‐fractional changes impact mainly the target coverage of combined and IMPT treatments, while OARs doses were less affected by these changes. With plan adaptation however, target coverage of combined treatments remained high even when taking variability between breath‐holds into account. Conclusions Optimally combined proton‐photon plans improve treatment plan quality compared to IMRT only, potentially reducing the risk of toxicity while also allowing to potentially increase accessibility to proton therapy for NSCLC patients.

Patient‐specific quality assurance for deformable IMRT/IMPT dose accumulation: Proposition and validation of energy conservation based validation criterion

“…Five different types of treatment [intensity‐modulated radiotherapy (IMRT), two intensity‐modulated proton therapy (IMPT), and two combined proton‐photon therapy (CPPT)] were studied individually to cover a broad range of treatment plans. The complete optimization framework, including the objectives, was recently published 22 . All dose distributions for one example patient are shown in Figure 2.…”

“…The CPPT Gantry plan simultaneously optimizes the IMPT Gantry with the IMRT fields, while the CPPT FHB is the optimal combination of the IMPT FHB and IMRT fields. The concept and potential of CPPT are described in other publications 23–27 . The purpose of examining various treatment modalities is to avoid limiting the investigations to a single treatment type.…”

“…The complete optimization framework, including the objectives, was recently published. 22 All dose distributions for one example patient are shown in Figure 2. Nine equispaced coplanar beams were used for the IMRT plan, while three patient-specific fields were used for IMPT Gantry.…”

“…The concept and potential of CPPT are described in other publications. [23][24][25][26][27] The purpose of examining various treatment modalities is to avoid limiting the investigations to a single treatment type.…”

Fraction optimization for hybrid proton‐photon treatment planning

“…The hybrid proton-photon RT has been clinically used for treating spine sarcoma, [9][10][11] for which photon and proton plans are optimized separately: protons are used to improve the OAR sparing that allows for dose escalation to targets, while photons are used to reduce the skin dose. Recently various hybrid proton-photon treatment planning methods with joint optimization of proton and photon variables have been proposed with different motivations and outcomes, [12][13][14][15][16][17][18][19] for various sites including skull-base, head-and-neck (HN), breast, and lung cancer. To solve the problem that proton RT is a limited resource, Unkelbach et al proposed a hybrid planning method with the plan quality that is no worse than proton plans.…”