Development, commissioning, and evaluation of a new intensity modulated minibeam proton therapy system

Very high-energy electron therapy as light-particle alternative to transmission proton FLASH therapy - An evaluation of dosimetric performances

PURPOSE

Clinical translation of FLASH-radiotherapy (RT) to deep-seated tumours is still a technological challenge. One proposed solution consists of using ultra-high dose rate transmission proton (TP) beams of about 200-250 MeV to irradiate the tumour with the flat entrance of the proton depth-dose profile. This work evaluates the dosimetric performance of very high-energy electron (VHEE)-based RT (50-250 MeV) as a potential alternative to TP-based RT for the clinical transfer of the FLASH effect.

METHODS

Basic physics characteristics of VHEE and TP beams were compared utilizing Monte Carlo simulations in water. A VHEE-enabled research treatment planning system was used to evaluate the plan quality achievable with VHEE beams of different energies, compared to 250 MeV TP beams for a glioblastoma, an oesophagus, and a prostate cancer case.

RESULTS

Like TP, VHEE above 100 MeV can treat targets with roughly flat (within ± 20 %) depth-dose distributions. The achievable dosimetric target conformity and adjacent organs-at-risk (OAR) sparing is consequently driven for both modalities by their lateral beam penumbrae. Electron beams of 400[500] MeV match the penumbra of 200[250] MeV TP beams and penumbra is increased for lower electron energies. For the investigated patient cases, VHEE plans with energies of 150 MeV and above achieved a dosimetric plan quality comparable to that of 250 MeV TP plans. For the glioblastoma and the oesophagus case, although having a decreased conformity, even 100 MeV VHEE plans provided a similar target coverage and OAR sparing compared to TP.

CONCLUSIONS

VHEE-based FLASH-RT using sufficiently high beam energies may provide a lighter-particle alternative to TP-based FLASH-RT with comparable dosimetric plan quality.

Commissioning dose computation model for proton source in pencil beam scanning therapy by convolution neural networks

Objective. Proton source model commissioning (PSMC) is critical for ensuring accurate dose calculation in pencil beam scanning (PBS) proton therapy using Monte Carlo (MC) simulations. PSMC aims to match the calculated dose to the delivered dose. However, commissioning the 'nominal energy' and 'energy spread' parameters in PSMC can be challenging, as these parameters cannot be directly obtained from solving equations. To efficiently and accurately commission the nominal energy and energy spread in a proton source model, we developed a convolution neural network (CNN) named 'PSMC-Net.'Methods. The PSMC-Net was trained separately for 33 energies (E, 70-225 MeV with a step of 5 MeV plus 226.09 MeV). For eachE, a dataset was generated consisting of 150 source model parameters (15 nominal energies ∈ [E,E+ 1.5 MeV], ten spreads ∈ [0, 1]) and the corresponding 150 MC integrated depth doses (IDDs). Of these 150 data pairs, 130 were used for training the network, 10 for validation, and 10 for testing.Results. The source model, built by 33 measured IDDs and 33 PSMC-Nets (cost 0.01 s), was used to compute the MC IDDs. The gamma passing rate (GPRs, 1 mm/1%) between MC and measured IDDs was 99.91 ± 0.12%. However, when no commissioning was made, the corresponding GPR was reduced to 54.11 ± 22.36%, highlighting the tremendous significance of our CNN commissioning method. Furthermore, the MC doses of a spread-out Bragg peak and 20 patient PBS plans were also calculated, and average 3D GPRs (2 mm/2% with a 10% threshold) were 99.89% and 99.96 ± 0.06%, respectively.Significance. We proposed a nova commissioning method of the proton source model using CNNs, which made the PSMC process easy, efficient, and accurate.

TVL1-IMPT: Optimization of Peak-to-Valley Dose Ratio Via Joint Total-Variation and L1 Dose Regularization for Spatially Fractionated Pencil-Beam-Scanning Proton Therapy

PURPOSE

Proton minibeam radiation therapy (pMBRT) is a novel proton modality of spatially fractionated RT. pMBRT can reduce the radiation damage to normal tissues via biological dose sparing of high peak-to-valley dose ratio (PVDR). This work will develop a new spatially fractionated IMPT treatment planning method for pMBRT that jointly optimizes the plan quality and maximizes the PVDR.

METHODS

The new optimization method simultaneously maximizes the normal-tissue PVDR and optimizes the dose distribution at tumor targets and organs at risk. The PVDR maximization is through the joint total variation (TV) and L1 regularization with respect to the normal-tissue dose. That is, the beam-eye view projects dose slices of several depths for each beam angle; the TV of dose is maximized, corresponding to the PVDR maximization; and the L1 of dose is minimized, corresponding to the minimization of the organs-at-risk dose and maximization of survival fraction (SF).

RESULTS

The new IMPT method with TV and L1 regularization was validated in comparison with the conventional IMPT method for pMBRT in several clinical cases. The results show that TVL1 provided larger PVDR and SF than the conventional IMPT method for biological sparing of normal tissues, with preserved plan quality in terms of physical dose distribution.

CONCLUSIONS

A new spatially fractionated IMPT treatment planning method was developed for pMBRT that can optimize and improve normal-tissue PVDR and SF by incorporating TV and L1 dose regularization with properly chosen regularization parameters into IMPT.

Uniformity calibration for large area XY strip parallel plate ionization chamber

Demand for large area parallel plate ionization chamber (PPIC) or large area ionization chamber (LAIC) has risen in recent years due to several advantages of the large effective area in monitoring therapeutic radiation beams. PPICs are designed for the measurements of beam profile and dosimetry in radiation therapy quality assurance (QA) procedures.Objective. Heterogeneous responses over the large sensitive area pose an undeniable concern for the straightforward applications of PPICs in clinical dosimetry. Uniformity calibration for the detector response is thus essential for the accurate performance of each PPIC unit.Approach.A large area XY strip PPIC, characterized by a large effective area of 345.44 × 345.44 mm²and 256 readout channels, was investigated in this study. A new systematic uniformity calibration is developed to improve the lateral response of the PPIC over the measurements for both narrow beams and large square field beams. A 2D response map of the PPIC was obtained by a spot-scanning method using a compact x-ray tube (mini x-ray). The mini x-ray, providing stable radiation (uncertainty <0.1%), was moved with a step size of 20 mm in 2 dimensions across the entire PPIC surface to collect a complete spot scan. Different uniformity calibration methods were introduced for the measurement of the PPIC by adopting the information from the detector 2D response map.Main results.Deviation of the detector response, before calibration, was observed to reach about 7% for the testing PPIC unit which is much higher than the recommended uniformity response of 1% (IAEA TRS-398). The uniformity response of the PPIC improved significantly to less than 1% across the detector surface after calibration.Significance.The proposed methods enable the practical application of PPIC in routine clinical dosimetry and can be reliably adopted by any radiation facility to perform daily and monthly QA.

Treatment-planning approaches to intensity modulated proton therapy and the impact on dose-weighted linear energy transfer

PURPOSE

We quantified the effect of various forward-based treatment-planning strategies in proton therapy on dose-weighted linear energy transfer (LETd). By maintaining the dosimetric quality at a clinically acceptable level, we aimed to evaluate the differences in LETd among various treatment-planning approaches and their practicality in minimizing biologic uncertainties associated with LETd.

METHOD

Eight treatment-planning strategies that are achievable in commercial treatment-planning systems were applied on a cylindrical water phantom and four pediatric brain tumor cases. Each planning strategy was compared to either an opposed lateral plan (phantom study) or original clinical plan (patient study). Deviations in mean and maximum LETd from clinically acceptable dose distributions were compared.

RESULTS

In the phantom study, using a range shifter and altering the robust scenarios during optimization had the largest effect on the mean clinical target volume LETd, which was reduced from 4.5 to 3.9 keV/μm in both cases. Variations in the intersection angle between beams had the largest effect on LETd in a ring defined 3 to 5 mm outside the target. When beam intersection angles were reduced from opposed laterals (180°) to 120°, 90°, and 60°, corresponding maximum LETd increased from 7.9 to 8.9, 10.9, and 12.2 keV/μm, respectively. A clear trend in mean and maximum LETd variations in the clinical cases could not be established, though spatial distribution of LETd suggested a strong dependence on patient anatomy and treatment geometry.

CONCLUSION

Changes in LETd from treatment-plan setup follow intuitive trends in a controlled phantom experiment. Anatomical and other patient-specific considerations, however, can preclude generalizable strategies in clinical cases. For pediatric cranial radiation therapy, we recommend using opposed lateral treatment fields to treat midline targets.

Monte Carlo framework for commissioning a synchrotron-based discrete spot scanning proton beam system and treatment plan verification

This study aimed to develop a Monte Carlo (MC) framework for commissioning the narrow proton beams (spot size sigma, 5.2 mm 2 mm at isocenter for 69.4 MeV-221.3 MeV for the main beam option and 4.1 mm 1.3 mm for the minibeam option respectively) of a synchrotron-based proton therapy system and design an independent absolute dose calculation engine for intensity-modulated proton treatments. A proton therapy system (Hitachi PROBEAT-V) was simulated using divergent and convergent beam models at the nozzle entrance. The innovative source weighting scheme for the MC simulation with TOPAS (TOol for PArticle Simulations) was implemented using dose output data for the absolute dose calculations. The results of the MC simulation were compared to the experimental data, analyzed and used to commission the treatment planning system. Two MC models, divergent and convergent beams were implemented. The convergent beam model produced a high level of agreement when MC and measurements were analyzed. The beam ellipticity did not result in significant differences between MC simulated and treatment planning system calculated doses. A model of a synchrotron-based spot scanning proton therapy system has been developed and implemented in the TOPAS MC transport code framework. The dose computation engine is useful for treatment plan verification with primary and minibeam beam option.

Proton therapy delivery method affects dose-averaged linear energy transfer in patients

The dosimetric advantages of proton therapy have led to its rapid proliferation in recent decades. This has been accompanied by a shift in technology from older units that deliver protons by passive scattering (PS) to newer units that increasingly use pencil-beam scanning (PBS). The biologic effectiveness of proton physical dose purportedly rises with increasing dose-weighted average linear energy transfer (LET_D). The objective of this study was to determine the extent to which proton delivery methods affect LET_D. We calculated LET_Dfrom simple, dosimetrically matched, and clinical treatment plans with TOPAS Monte-Carlo transport code. Simple treatment plans comprised single fields of PS and PBS protons in a water phantom. We performed simulations of matched and clinical treatment plans by using the treatment and anatomic data obtained from a cohort of children with craniopharyngioma who previously received PS or PBS proton therapy. We compared the distributions of LET_Dfrom PS and PBS delivery methods in clinically relevant ROIs. Wilcoxon signed-rank tests comparing single fields in water revealed that the LET_Dvalues from PBS were significantly greater than those from PS inside and outside the targeted volume (p < 0.01). Statistical tests comparing LET_D-volume histograms from matched and clinical treatment plans showed that LET_Dwas generally greater for PBS treatment plans than for PS treatment plans (p < 0.05). In conclusion, the proton delivery method affects LET_Dboth inside and outside of the target volume. These findings suggest that PBS is more biologically effective than PS. Given the rapid expansion of PBS proton therapy, future studies are needed to confirm the applicability of treatment evaluation methods developed for PS proton therapy to those for modern PBS treatments to ensure their safety and effectiveness for the growing population of patients receiving proton therapy. This study uses data from two clinical trials: NCT01419067 and NCT02792582.

Biological and Mechanical Synergies to Deal With Proton Therapy Pitfalls: Minibeams, FLASH, Arcs, and Gantryless Rooms

Proton therapy has advantages and pitfalls comparing with photon therapy in radiation therapy. Among the limitations of protons in clinical practice we can selectively mention: uncertainties in range, lateral penumbra, deposition of higher LET outside the target, entrance dose, dose in the beam path, dose constraints in critical organs close to the target volume, organ movements and cost. In this review, we combine proposals under study to mitigate those pitfalls by using individually or in combination: (a) biological approaches of beam management in time (very high dose rate “FLASH” irradiations in the order of 100 Gy/s) and (b) modulation in space (a combination of mini-beams of millimetric extent), together with mechanical approaches such as (c) rotational techniques (optimized in partial arcs) and, in an effort to reduce cost, (d) gantry-less delivery systems. In some cases, these proposals are synergic (e.g., FLASH and minibeams), in others they are hardly compatible (mini-beam and rotation). Fixed lines have been used in pioneer centers, or for specific indications (ophthalmic, radiosurgery,…), they logically evolved to isocentric gantries. The present proposals to produce fixed lines are somewhat controversial. Rotational techniques, minibeams and FLASH in proton therapy are making their way, with an increasing degree of complexity in these three approaches, but with a high interest in the basic science and clinical communities. All of them must be proven in clinical applications.

Clinical commissioning of intensity-modulated proton therapy systems: Report of AAPM Task Group 185

Proton therapy is an expanding radiotherapy modality in the United States and worldwide. With the number of proton therapy centers treating patients increasing, so does the need for consistent, high-quality clinical commissioning practices. Clinical commissioning encompasses the entire proton therapy system's multiple components, including the treatment delivery system, the patient positioning system, and the image-guided radiotherapy components. Also included in the commissioning process are the x-ray computed tomography scanner calibration for proton stopping power, the radiotherapy treatment planning system, and corresponding portions of the treatment management system. This commissioning report focuses exclusively on intensity-modulated scanning systems, presenting details of how to perform the commissioning of the proton therapy and ancillary systems, including the required proton beam measurements, treatment planning system dose modeling, and the equipment needed.

Beam data modeling of linear accelerators (linacs) through machine learning and its potential applications in fast and robust linac commissioning and quality assurance

BACKGROUND AND PURPOSE

To propose a novel machine learning-based method for reliable and accurate modeling of linac beam data applicable to the processes of linac commissioning and QA.

MATERIALS AND METHODS

We hypothesize that the beam data is a function of inherent linac features and percentage depth doses (PDDs) and profiles of different field sizes are correlated with each other. The correlation is formulated as a multivariable regression problem using a machine learning framework. Varian TrueBeam beam data sets (n = 43) acquired from multiple institutions were used to evaluate the framework. The data sets included PDDs and profiles across different energies and field sizes. A multivariate regression model was trained for prediction of beam specific PDDs and profiles of different field sizes using a 10 × 10 cm² field as input.

RESULTS

Predictions of PDDs were achieved with a mean absolute percent relative error (%RE) of 0.19-0.35% across the different beam energies investigated. The maximum mean absolute %RE was 0.93%. For profile prediction, the mean absolute %RE was 0.66-0.93% with a maximum absolute %RE of 3.76%. The largest uncertainties in the PDD and profile predictions were found at the build-up region and at the field penumbra, respectively. The prediction accuracy increased with the number of training sets up to around 20 training sets.

CONCLUSIONS

Through this novel machine learning-based method we have shown accurate and reproducible generation of beam data for linac commissioning for routine radiation therapy. This method has the potential to simplify the linac commissioning procedure, save time and manpower while increasing the accuracy of the commissioning process.

ASSESSMENT OF AMBIENT NEUTRON DOSE EQUIVALENT IN SPATIALLY FRACTIONATED RADIOTHERAPY WITH PROTONS USING PHYSICAL COLLIMATORS

New technique is trending in spatially fractionated radiotherapy with protons to utilize the spot scanning together with a physical collimator to obtain minibeams. The primary goal of this study is to quantify ambient neutron dose equivalent (${H}^{\ast }(10)$) due to the secondary neutrons when physical collimator is used to achieve desired minibeams. The ${H}^{\ast }(10)$ per treatment proton dose (D) was assessed using Monte Carlo code TOPAS and measured using WENDI-II detector at different angles (135, 180, 225 and 270 degrees) and distances (11 cm, 58 and 105 cm) from the phantom for two cases: with and without physical collimation. Without collimation $\frac{H^{\ast }(10)}{D}$ varied from 0.0013 to 0.242 mSv/Gy. With collimation $\frac{H^{\ast }(10)}{D}$ varied from 0.017 to 3.23 mSv/Gy. Results show that the secondary neutron dose will increase tenfold when the physical collimator is used. Regardless, it will be low and comparable to the neutron dose produced by conventional passive-scattered proton beams.

Automation of Monte Carlo-based treatment plan verification for proton therapy

Purpose

Independent calculations of proton therapy plans are an important quality control procedure in treatment planning. When using custom Monte Carlo (MC) models of the beamline, deploying the calculations can be laborious, time consuming, and require in‐depth knowledge of the computational environment. We developed an automated framework to remove these barriers and integrate our MC model into the clinical workflow.

Materials and Methods

The Eclipse Scripting Application Programming Interface was used to initiate the automation process. A series of MATLAB scripts were then used for preprocessing of input data and postprocessing of results. Additional scripts were used to monitor the calculation process and appropriately deploy calculations to an institutional high‐performance computing facility. The automated framework and beamline models were validated against 160 patient specific QA measurements from an ionization chamber array and using a ±3%/3 mm gamma criteria.

Results

The automation reduced the human‐hours required to initiate and run a calculation to 1–2 min without leaving the treatment planning system environment. Validation comparisons had an average passing rate of 99.4% and were performed at depths ranging from 1 to 15 cm.

Conclusion

An automated framework for running MC calculations was developed which enables the calculation of dose and linear energy transfer within a clinically relevant workflow and timeline. The models and framework were validated against patient specific QA measurements and exhibited excellent agreement. Before this implementation, execution was prohibitively complex for an untrained individual and its use restricted to a research environment.

Advancing proton minibeam radiation therapy: magnetically focussed proton minibeams at a clinical centre

Proton minibeam radiation therapy (pMBRT) is a novel therapeutic strategy that has proven to significantly increase dose tolerances and sparing of normal tissue. It uses very narrow proton beams (diameter ≤1 mm), roughly one order of magnitude smaller than state-of-the-art pencil beams. The current implementation of pMBRT with mechanical collimators is suboptimal as it is inflexible, decreases efficiency and produces additional secondary neutrons. As a potential solution, we explore in this article minibeam generation through magnetic focussing and investigate possibilities for the integration of such a technique at existing clinical centres. For this, a model of the pencil beam scanning (PBS) nozzle and beam at the Orsay Proton Therapy Centre was established and Monte Carlo simulations were performed to determine its focussing capabilities. Moreover, various modifications of the nozzle geometry were considered. It was found that the PBS nozzle in its current state is not suitable for magnetic minibeam generation. Instead, a new, optimised nozzle design has been proposed and conditions necessary for minibeam generation were benchmarked. In addition, dose simulations in a water phantom were performed which showed improved dose distributions compared to those obtained with mechanical collimators.

Spatially fractionated proton minibeams

Extraordinary normal tissue response to highly spatially fractionated X-ray beams has been explored for over 25 years. More recently, alternative radiation sources have been developed and utilized with the aim to evoke comparable effects. These include protons, which lend themselves well for this endeavour due to their physical depth dose characteristics as well as corresponding variable biological effectiveness. This paper addresses the motivation for using protons to generate spatially fractionated beams and reviews the technological implementations and experimental results to date. This includes simulation and feasibility studies, collimation and beam characteristics, dosimetry and biological considerations as well as the results of in vivo and in vitro studies. Experimental results are emerging indicating an extraordinary normal tissue sparing effect analogous to what has been observed for synchrotron generated X-ray microbeams. The potential for translational research and feasibility of spatially modulated proton beams in clinical settings is discussed.