title: Proton therapy in adjuvant treatment of gastric cancer: planning comparison with advanced x-ray therapy and feasibility report.
abstract: BACKGROUND
  Adjuvant chemoradiotherapy improves both overall- and relapse-free survival in patients with resected gastric cancer. However, this comes at the cost of increased treatment-related toxicity. Proton therapy (PT) has distinct dosimetric characteristics that may reduce dose to normal tissues, improving the therapeutic ratio. The purpose of this treatment planning study is to compare PT and intensity-modulated x-ray therapy (IMXT) in gastric cancer with regards to normal tissue sparing.
  
  
  METHODS
  The patient population consisted of resected gastric cancer patients treated at a single institution between 2008 and 2013. Patients who had undergone 4D CT simulation were replanned to the originally delivered doses (45-54 Gy in 25-30 daily fractions) using six-field photon IMXT and 2-3-field PT (double scattering-uniform scanning techniques).
  
  
  RESULTS
  Thirteen patients were eligible for the planning comparison. IMXT provided slightly higher homogeneity indices (median values 0.04 ± 0.01 vs. 0.07 ± 0.01, p = 0.03). PT resulted in significantly (p < 0.05) lower intermediate-low doses for all the normal tissues examined (small bowel V15 82 ml vs. 133 ml, liver mean doses Gy 11.9 vs. 14.4 Gy, left/right kidney mean doses 5/0.9 Gy vs. 7.8/3.1 Gy, heart mean doses 7.4 Gy vs. 9.5 Gy). The total energy deposited outside the target volume was significantly lower with PT (median integral dose 90.1 J vs. 129 J). Four patients were treated with PT: treatment was feasible and verifications scans showed that target coverage was robust.
  
  
  CONCLUSIONS
  PT can contribute to normal tissue sparing in the adjuvant treatment of gastric cancer, with a potential benefit in terms of compliance to treatment, acute and late toxicities.
authors.affiliation: Proton Therapy Unit, Department of Oncology, Azienda Provinciale per i Servizi Sanitari (APSS) , Trento , Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Dionisi
authors.forename: Stephen
authors.initials: S
authors.lastname: Avery
authors.forename: John N
authors.initials: JN
authors.lastname: Lukens
authors.forename: Xuanfeng
authors.initials: X
authors.lastname: Ding
authors.forename: John
authors.initials: J
authors.lastname: Kralik
authors.forename: Maura
authors.initials: M
authors.lastname: Kirk
authors.forename: Robert E
authors.initials: RE
authors.lastname: Roses
authors.forename: Maurizio
authors.initials: M
authors.lastname: Amichetti
authors.forename: James M
authors.initials: JM
authors.lastname: Metz
authors.forename: John P
authors.initials: JP
authors.lastname: Plastaras
mesh_terms: D005240:Feasibility Studies; D006801:Humans; D059351:Organ Sparing Treatments / Q000379:methods; D058958:Organs at Risk / Q000000981:diagnostic imaging / Q000528:radiation effects*; D061766:Proton Therapy / Q000379:methods*; D011832:Radiation Injuries / Q000517:prevention & control; D011859:Radiography; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods*; D013274:Stomach Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery