World’s first patient treatments delivered with proton arc therapy
A team at the Trento Proton Therapy Centre in Italy has delivered the first clinical treatments using proton arc therapy, an emerging proton delivery technique. Following successful dosimetric comparisons with clinically delivered proton plans, the researchers confirmed the feasibility of PAT delivery and used PAT to treat nine cancer patients, reporting their findings in Medical Physics.
Currently, proton therapy is mostly delivered using pencil-beam scanning (PBS), which provides highly conformal dose distributions. But PBS delivery can be compromised by the small number of beam directions deliverable in an acceptable treatment time. PAT overcomes this limitation by moving to an arc trajectory.
“Proton arc treatments are different from any other pencil-beam proton delivery technique because of the large number of beam angles used and the possibility to optimize the number of energies used for each beam direction, which enables optimization of the delivery time,” explains first author Francesco Fracchiolla. “The ability to optimize both the number of energy layers and the spot weights makes these treatments superior to any previous delivery technique.”
Plan comparisons
The Trento researchers – working with colleagues from RaySearch Laboratories – compared the dosimetric parameters of PAT plans with those of state-of-the-art multiple-field optimized (MFO) PBS plans, for 10 patients with head-and-neck cancer. They focused on this site due to the high number of organs-at-risk (OARs) close to the target that may be spared using this new technique.
In future, PAT plans will be delivered with the beam on during gantry motion (dynamic mode). This requires dynamic arc plan delivery with all system settings automatically adjusted as a function of gantry angle – an approach with specific hardware and software requirements that have so far impeded clinical rollout.
Instead, Fracchiolla and colleagues employed an alternative version of static PAT, in which the static arc is converted into a series of PBS beams and delivered using conventional delivery workflows. Using the RayStation treatment planning system, they created MFO plans (using six noncoplanar beam directions) and PAT plans (with 30 beam directions), robustly optimized against setup and range uncertainties.
PAT plans dramatically improved dose conformality compared with MFO treatments. While target coverage was of equal quality for both treatment types, PAT decreased the mean doses to OARs for all patients. The biggest impact was in the brainstem, where PAT reduced maximum and mean doses by 19.6 and 9.5 Gy(RBE), respectively. Dose to other primary OARs did not differ significantly between plans, but PAT achieved an impressive reduction in mean dose to secondary OARs not directly adjacent to the target.
The team also evaluated how these dosimetric differences impact normal tissue complication probability (NTCP). PAT significantly reduced (by 8.5%) the risk of developing dry mouth and slightly lowered other NTCP endpoints (swallowing dysfunction, tube feeding and sticky saliva).
To verify the feasibility of clinical PAT, the researchers delivered MFO and PAT plans for one patient on a clinical gantry. Importantly, delivery times (from the start of the first beam to the end of the last) were similar for both techniques: 36 min for PAT with 30 beam directions and 31 min for MFO. Reducing the number of beam directions to 20 reduced the delivery time to 25 min, while maintaining near-identical dosimetric data.
First patient treatments
The successful findings of the plan comparison and feasibility test prompted the team to begin clinical treatments.
“The final trigger to go live was the fact that the discretized PAT plans maintained pretty much exactly the optimal dosimetric characteristics of the original dynamic (continuous rotation) arc plan from which they derived, so there was no need to wait for full arc to put the potential benefits to clinical use. Pretreatment verification showed excellent dosimetric accuracy and everything could be done in a fully CE-certified environment,” say Frank Lohr and Marco Cianchetti, director and deputy director, respectively, of the Trento Proton Therapy Center. “The only current drawback is that we are not at the treatment speed that we could be with full dynamic arc.”
To date, nine patients have received or are undergoing PAT treatment: five with head-and-neck tumours, three with brain tumours and one thorax cancer. For the first two head-and-neck patients, the team created PAT plans with a half arc (180° to 0°) with 10 beam directions and a mean treatment time of 12 min. The next two were treated with a complete arc (360°) with 20 beam directions. Here, the mean treatment time was 24 min. Patient-specific quality assurance revealed an average gamma passing rate (3%, 3 mm) of 99.6% and only one patient required replanning.
All PAT treatments were performed using the centre’s IBA ProteusPlus proton therapy unit and the existing clinical workflow. “Our treatment planning system can convert an arc plan into a PBS plan with multiple beams,” Fracchiolla explains. “With this workaround, the entire clinical chain doesn’t change and the plan can be delivered on the existing system. This ability to convert the arc plans into PBS plans means that basically every proton centre can deliver these treatments with the current hardware settings.”
The researchers are now analysing acute toxicity data from the patients, to determine whether PAT reduces toxicity. They are also looking to further reduce the delivery times.
“Hopefully, together with IBA, we will streamline the current workflow between the OIS [oncology information system] and the treatment control system to reduce treatment times, thus being competitive in comparison with conventional approaches, even before full dynamic arc treatments become a clinical reality,” adds Lohr.
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