title: Initial Report of Pencil Beam Scanning Proton Therapy for Posthysterectomy Patients With Gynecologic Cancer.
abstract: OBJECTIVE
  To report the acute toxicities associated with pencil beam scanning proton beam radiation therapy (PBS) for whole pelvis radiation therapy in women with gynecologic cancers and the results of a dosimetric comparison of PBS versus intensity modulated radiation therapy (IMRT) plans.
  
  
  METHODS
  Eleven patients with posthysterectomy gynecologic cancer received PBS to the whole pelvis. The patients received a dose of 45 to 50.4 Gy relative biological effectiveness (RBE) in 1.8 Gy (RBE) daily fractions. Acute toxicity was scored according to the Common Terminology Criteria for Adverse Events, version 4. A dosimetric comparison between a 2-field posterior oblique beam PBS and an IMRT plan was conducted. The Wilcoxon signed rank test was used to assess the potential dosimetric differences between the 2 plans and PBS target coverage robustness relative to setup uncertainties.
  
  
  RESULTS
  The median patient age was 55 years (range 23-76). The primary site was cervical in 7, vaginal in 1, and endometrial in 3. Of the 11 patients, 7 received concurrent cisplatin, 1 each received sandwich carboplatin and paclitaxel chemotherapy, both sandwich and concurrent chemotherapy, and concurrent and adjuvant chemotherapy, and 1 received no chemotherapy. All patients completed treatment. Of the 9 patients who received concurrent chemotherapy, the rate of grade 2 and 3 hematologic toxicities was 33% and 11%, respectively. One patient (9%) developed grade 3 acute gastrointestinal toxicity; no patient developed grade ≥3 genitourinary toxicity. The volume of pelvic bone marrow, bladder, and small bowel receiving 10 to 30 Gy was significantly lower with PBS than with intensity modulated radiation therapy (P<.001). The target coverage for all PBS plans was robust relative to the setup uncertainties (P>.05) with the clinical target volume mean dose percentage received by 95% and 98% of the target volume coverage changes within 2% for the individual plans.
  
  
  CONCLUSIONS
  Our results have demonstrated the clinical feasibility of PBS and the dosimetric advantages, especially for the low-dose sparing of normal tissues in the pelvis with the target robustness maintained relative to the setup uncertainties. Future studies with larger patient numbers are planned to further validate our preliminary findings.
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. Electronic address: lin@xrt.upenn.edu.
authors.forename: Lilie L
authors.initials: LL
authors.lastname: Lin
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Maura
authors.initials: M
authors.lastname: Kirk
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Jessica
authors.initials: J
authors.lastname: Scholey
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Nicolette
authors.initials: N
authors.lastname: Taku
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Janid B
authors.initials: JB
authors.lastname: Kiely
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Benjamin
authors.initials: B
authors.lastname: White
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Stefan
authors.initials: S
authors.lastname: Both
mesh_terms: D000328:Adult; D000368:Aged; D000970:Antineoplastic Agents / Q000627:therapeutic use; D016889:Endometrial Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy* / Q000601:surgery; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007044:Hysterectomy; D007421:Intestine, Small / Q000528:radiation effects; D015182:Lymphatic Irradiation / Q000379:methods; D008875:Middle Aged; D059351:Organ Sparing Treatments / Q000009:adverse effects / Q000379:methods; D058958:Organs at Risk / Q000528:radiation effects; D010384:Pelvic Bones / Q000528:radiation effects; D010388:Pelvis; D011184:Postoperative Period; D011446:Prospective Studies; D061766:Proton Therapy / Q000009:adverse effects / Q000379:methods*; D011859:Radiography; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000009:adverse effects / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects / Q000379:methods*; D000069475:Re-Irradiation / Q000706:statistics & numerical data; D012062:Relative Biological Effectiveness; D001743:Urinary Bladder / Q000528:radiation effects; D002583:Uterine Cervical Neoplasms / Q000532:radiotherapy* / Q000601:surgery; D014625:Vaginal Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy* / Q000601:surgery
chemical_list: D000970:Antineoplastic Agents