Improvements in pencil beam scanning proton therapy dose calculation accuracy in brain tumor cases with a commercial Monte Carlo algorithm

A commercial Monte Carlo (MC) algorithm (RayStation version 6.0.024) for the treatment of brain tumors with pencil beam scanning (PBS) proton therapy is validated and compared via measurements and analytical calculations in clinically realistic scenarios. For the measurements a 2D ion chamber array detector (MatriXX PT) was placed underneath the following targets: (1) an anthropomorphic head phantom (with two different thicknesses) and (2) a biological sample (i.e. half a lamb's head). In addition, we compared the MC dose engine versus the RayStation pencil beam (PB) algorithm clinically implemented so far, in critical conditions such as superficial targets (i.e. in need of a range shifter (RS)), different air gaps, and gantry angles to simulate both orthogonal and tangential beam arrangements. For every plan the PB and MC dose calculations were compared to measurements using a gamma analysis metrics (3%, 3 mm). For the head phantom the gamma passing rate (GPR) was always  >96% and on average  >99% for the MC algorithm; the PB algorithm had a GPR of  ⩽90% for all the delivery configurations with a single slab (apart 95% GPR from the gantry of 0° and small air gap) and in the case of two slabs of the head phantom the GPR was  >95% only in the case of small air gaps for all three (0°, 45°, and 70°) simulated beam gantry angles. Overall the PB algorithm tends to overestimate the dose to the target (up to 25%) and underestimate the dose to the organ at risk (up to 30%). We found similar results (but a bit worse for the PB algorithm) for the two targets of the lamb's head where only two beam gantry angles were simulated. Our results suggest that in PBS proton therapy a range shifter (RS) needs to be used with caution when planning a treatment with an analytical algorithm due to potentially great discrepancies between the planned dose and the dose delivered to the patient, including in the case of brain tumors where this issue could be underestimated. Our results also suggest that a MC evaluation of the dose has to be performed every time the RS is used and, mostly, when it is used with large air gaps and beam directions tangential to the patient surface.

DCE-MRI Data Analysis for Cancer Area Classification

Objectives: The paper aims at improving the support of medical researchers in the context of in-vivo cancer imaging. Morphological and functional parameters obtained by dynamic contrast-enhanced MRI (DCE-MRI) techniques are analyzed, which aim at investigating the development of tumor microvessels. The main contribution consists in proposing a machine learning methodology to segment automatically these MRI data, by isolating tumor areas with different meaning, in a histological sense.

Methods: The proposed approach is based on a three-step procedure: i) robust feature extraction from raw time-intensity curves, ii) voxel segmentation, and iii) voxel classification based on a learning-by-example approach. In the first step, few robust features that compactly represent the response of the tissue to the DCE-MRI analysis are computed. The second step provides a segmentation based on the mean shift (MS) paradigm, which has recently shown to be robust and useful for different and heterogeneous clustering tasks. Finally, in the third step, a support vector machine (SVM) is trained to classify voxels according to the labels obtained by the clustering phase (i.e., each class corresponds to a cluster). Indeed, the SVM is able to classify new unseen subjects with the same kind of tumor.

Results: Experiments on different subjects affected by the same kind of tumor evidence that the extracted regions by both the MS clustering and the SVM classifier exhibit a precise medical meaning, as carefully validated by the medical researchers. Moreover, our approach is more stable and robust than methods based on quantification of DCE-MRI data by means of pharmacokinetic models.

Conclusions: The proposed method allows to analyze the DCE-MRI data more precisely and faster than previous automated or manual approaches.

Universal field matching in craniospinal irradiation by a background-dose gradient-optimized method

Purpose

The gradient‐optimized methods are overcoming the traditional feathering methods to plan field junctions in craniospinal irradiation. In this note, a new gradient‐optimized technique, based on the use of a background dose, is described.

Methods

Treatment planning was performed by RayStation (RaySearch Laboratories, Stockholm, Sweden) on the CT scans of a pediatric patient. Both proton (by pencil beam scanning) and photon (by volumetric modulated arc therapy) treatments were planned with three isocenters. An ‘in silico’ ideal background dose was created first to cover the upper‐spinal target and to produce a perfect dose gradient along the upper and lower junction regions. Using it as background, the cranial and the lower‐spinal beams were planned by inverse optimization to obtain dose coverage of their relevant targets and of the junction volumes. Finally, the upper‐spinal beam was inversely planned after removal of the background dose and with the previously optimized beams switched on.

Results

In both proton and photon plans, the optimized cranial and the lower‐spinal beams produced a perfect linear gradient in the junction regions, complementary to that produced by the optimized upper‐spinal beam. The final dose distributions showed a homogeneous coverage of the targets.

Discussion

Our simple technique allowed to obtain high‐quality gradients in the junction region. Such technique universally works for photons as well as protons and could be applicable to the TPSs that allow to manage a background dose.

Model-based approach for quantitative estimates of skin, heart, and lung toxicity risk for left-side photon and proton irradiation after breast-conserving surgery

BACKGROUND

Proton beam therapy represents a promising modality for left-side breast cancer (BC) treatment, but concerns have been raised about skin toxicity and poor cosmesis. The aim of this study is to apply skin normal tissue complication probability (NTCP) model for intensity modulated proton therapy (IMPT) optimization in left-side BC.

MATERIAL AND METHODS

Ten left-side BC patients undergoing photon irradiation after breast-conserving surgery were randomly selected from our clinical database. Intensity modulated photon (IMRT) and IMPT plans were calculated with iso-tumor-coverage criteria and according to RTOG 1005 guidelines. Proton plans were computed with and without skin optimization. Published NTCP models were employed to estimate the risk of different toxicity endpoints for skin, lung, heart and its substructures.

RESULTS

Acute skin NTCP evaluation suggests a lower toxicity level with IMPT compared to IMRT when the skin is included in proton optimization strategy (0.1% versus 1.7%, p < 0.001). Dosimetric results show that, with the same level of tumor coverage, IMPT attains significant heart and lung dose sparing compared with IMRT. By NTCP model-based analysis, an overall reduction in the cardiopulmonary toxicity risk prediction can be observed for all IMPT compared to IMRT plans: the relative risk reduction from protons varies between 0.1 and 0.7 depending on the considered toxicity endpoint.

CONCLUSIONS

Our analysis suggests that IMPT might be safely applied without increasing the risk of severe acute radiation induced skin toxicity. The quantitative risk estimates also support the potential clinical benefits of IMPT for left-side BC irradiation due to lower risk of cardiac and pulmonary morbidity. The applied approach might be relevant on the long term for the setup of cost-effectiveness evaluation strategies based on NTCP predictions.

Single-energy intensity modulated proton therapy

In this note, an intensity modulated proton therapy (IMPT) technique, based on the use of high single-energy (SE-IMPT) pencil beams, is described.The method uses only the highest system energy (226 MeV) and only lateral penumbra to produce dose gradient, as in photon therapy. In the study, after a preliminary analysis of the width of proton pencil beam penumbras at different depths, SE-IMPT was compared with conventional IMPT in a phantom containing titanium inserts and in a patient, affected by a spinal chordoma with fixation rods.It was shown that SE-IMPT has the potential to produce a sharp dose gradient and that it is not affected by the uncertainties produced by metal implants crossed by the proton beams. Moreover, in the chordoma patient, target coverage and organ at risk sparing of the SE-IMPT plan resulted comparable to that of the less reliable conventional IMPT technique. Robustness analysis confirmed that SE-IMPT was not affected by range errors, which can drastically affect the IMPT plan.When accepting a low-dose spread as in modern photon techniques, SE-IMPT could be an option for the treatment of lesions (e.g. cervical bone tumours) where steep dose gradient could improve curability, and where range uncertainty, due for example to the presence of metal implants, hampers conventional IMPT.

Axillary irradiation omitting axillary dissection in breast cancer: is there a role for shoulder-sparing proton therapy?

The recent EORTC 10981-22023 AMAROS trial showed that axillary radiotherapy and axillary lymph node dissection provide comparable local control and reduced lymphoedema in the irradiated group. However, no significant differences between the two groups in range of motion and quality of life were reported. It has been acknowledged that axillary irradiation could have induced some toxicity, particularly shoulder function impairment. In fact, conventional breast irradiation by tangential beams has to be modified to achieve full-dose coverage of the axillary nodes, including in the treatment field a larger portion of the shoulder structures. In this scenario, alternative irradiation techniques were discussed. Compared with modern photon techniques, axillary irradiation by proton therapy has the potential for sparing the shoulder without detrimental increase of the medium-to-low doses to the other normal tissues.