title: Fractionated Lung IMPT Treatments: Sensitivity to Setup Uncertainties and Motion Effects Based on Single-Field Homogeneity.
abstract: Treatment uncertainties in radiotherapy are either systematic or random. This study evaluates the sensitivity of fractionated intensity-modulated proton therapy (IMPT) lung treatments to systematic and random setup uncertainties. Treatments in which single-field homogeneity was restricted to within ±20% (IMPT20%) were compared to full IMPT (IMPTfull) for 10 patients with lung cancer. Four-dimensional Monte Carlo calculations were performed using patient computed tomography geometries with ±5 mm systematic or random setup uncertainties applied over a 35 × 2.5Gy(RBE) treatment course. Fifty fractionated courses were simulated for each patient using both IMPT delivery methods with random setup uncertainties applied each fraction and for 3 energy-dependent spot sizes (big spots, σ≈18-9 mm; intermediate spots, σ≈11-5 mm; and small spots, σ≈4-2 mm). These results were compared to Monte Carlo recalculations of the original treatment plan assuming zero setup uncertainty. Results are presented as the difference in equivalent uniform dose (ΔEUD), V95 (ΔV95), and target dose homogeneity (ΔD1-D99). Over the whole patient cohort, the ΔEUD was 2.0 ± 0.5 (big spots), 1.9 ± 0.7 (intermediate spots), and 1.3 ± 0.4 (small spots) times more sensitive to ±5 mm systematic setup uncertainties in IMPTfull compared to IMPT20% IMPTfull is 1.9 ± 0.9 (big spots), 2.1 ± 1.1 (intermediate spots), and 1.5 ± 0.6 (small spots) times more sensitive to random setup uncertainties than IMPT20% over a fractionated treatment course. The ΔV95 is at least 1.4 times more sensitive to systematic and random setup uncertainties for IMPTfull for all spot sizes considered. The ΔD1-D99 values coincided within uncertainty limits for both IMPT delivery methods for the 3 spot sizes considered, with higher mean values always observed for IMPTfull The paired t-test indicated that variations observed between IMPTfull and IMPT20% were significantly different for the majority of scenarios. Significantly larger variations were observed in ΔEUD and ΔV95 in IMPTfull lung treatments in addition to higher mean ΔD1-D99 The steep intra-target dose gradients in IMPTfull make it more susceptible to systematic and random setup uncertainties.
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA Department of Radiation Oncology Medical Physics, Shoalhaven Cancer Care Centre, Illawarra Shoalhaven Cancer & Haematology Network, Nowra, NSW, Australia stephen.dowdell@sesiahs.health.nsw.gov.au.
authors.forename: Stephen
authors.initials: S
authors.lastname: Dowdell
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA.
authors.forename: Clemens
authors.initials: C
authors.lastname: Grassberger
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA.
authors.forename: Greg
authors.initials: G
authors.lastname: Sharp
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA.
authors.forename: Harald
authors.initials: H
authors.lastname: Paganetti
mesh_terms: D006801:Humans; D008175:Lung Neoplasms / Q000532:radiotherapy*; D009010:Monte Carlo Method; D009038:Motion; D061766:Proton Therapy / Q000379:methods; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods; D014057:Tomography, X-Ray Computed
keywords: intensity-modulated proton therapy; interplay effect; lung cancer; proton therapy; setup uncertainties