The purpose of this study was to investigate the impact of complex patient geometries on the capability of analytical dose calculation algorithms to accurately predict the range of proton fields. Dose distributions predicted by an analytical pencil-beam algorithm were compared with those obtained using Monte Carlo simulations (TOPAS). A total of 508 passively scattered treatment fields were analyzed for 7 disease sites (liver, prostate, breast, medulloblastoma-spine, medulloblastoma-whole brain, lung and head & neck). Voxel-by-voxel comparisons were performed on two-dimensional distal dose surfaces calculated by pencil-beam and Monte Carlo algorithms to obtain the average range differences (ARD) and root mean square deviation (RMSD) for each field for the distal position of the 90% dose level (R90) and the 50% dose level (R50). The average dose degradation (ADD) of the distal falloff region, defined as the distance between the distal position of the 80% and 20% dose levels (R80-R20), was also analyzed. All ranges were calculated in water-equivalent distances.
Considering total range uncertainties and uncertainties from dose calculation alone, we were able to deduce site-specific estimations. For liver, prostate and whole brain fields our results demonstrate that a reduction of currently used uncertainty margins is feasible even without introducing Monte Carlo dose calculations. We recommend range margins of 2.8% + 1.2 mm for liver and prostate treatments and 3.1% + 1.2 mm for whole brain treatments, respectively. On the other hand, current margins seem to be insufficient for some breast, lung and head & neck patients, at least if used generically. If no case specific adjustments are applied, a generic margin of 6.3% + 1.2 mm would be needed for breast, lung and head & neck treatments. We conclude that currently used generic range uncertainty margins in proton therapy should be redefined site specific and that complex geometries may require a field specific adjustment. Routine verifications of treatment plans using Monte Carlo simulations are recommended for patients with heterogeneous geometries.