A method for selection of beam angles robust to intra-fractional motion in proton therapy of lung cancer

Abstract

Background. Proton therapy offers the potential for sparing the normal tissue surrounding the target. However, due to well-defined proton ranges around the Bragg peak, dose deposition is more sensitive to changes in the water equivalent path length (WEPL) than with photons. In this study, we assess WEPL variations caused by breathing-induced motion for all possible beam angles in a series of lung cancer patients. By studying the association between measures for WEPL variation and breathing-induced target dose degradation we aimed to develop and explore a tool to identify beam angles that are robust to patient-specific patterns of intra-fractional motion.

Material and methods. Using four-dimensional computed tomography (4DCT) images of three lung cancer patients we evaluated the impact of the WEPL changes on target dose coverage for a series of coplanar single-beam plans. The plans were optimised for the internal target volume (ITV) at the maximum intensity projection (MIP) CT for every 3° gantry interval. The plans were transferred to the ten 4DCT phases and the average reduction in ITV V₉₅ over the ten phases, relative to the original MIP CT calculation, was quantified. The target dose reduction was associated with the mean difference between the WEPL and the phase-averaged WEPL computed for all beam rays across all possible gantry-couch angle combinations.

Results. The gantry-couch angle maps showed areas of both high and low WEPL variation, with overall quite similar patterns yet with individual differences reflecting differences in tumour position and breathing-induced motion. The coplanar plans showed a strong association between WEPL changes and ITV V₉₅ reduction, with a correlation coefficient ranging between 0.92 and 0.98 for the three patients (p < 0.01).

Conclusion. We have presented a 4DCT-based method to quantify WEPL changes during the breathing cycle. The method identified proton field gantry-couch angle combinations that were either sensitive or robust to WEPL changes. WEPL variations along the beam path were associated with target under-dosage.

Acknowledgments

The authors would like to thank David Sarrut from Léon Bérnard Cancer Centre for providing the open source image data set used in this paper (available from http://www.creatis.insa-lyon.fr/rio/popi-model) and Michael Krämer from GSI for his advice and comments to the present manuscript. We would also like to acknowledge the target delineations performed by Morten Høyer, Aarhus University Hospital. O.C.M. was partially funded by a grant from Aarhus University.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.