An Integrated Physical Optimization Framework for Proton Stereotactic Body Radiation Therapy FLASH Treatment Planning Allows Dose, Dose Rate, and Linear Energy Transfer Optimization Using Patient-Specific Ridge Filters

Embracing the Future of Clinical Trials in Radiation Therapy: An NRG Oncology CIRO Technology Retreat Whitepaper on Pioneering Technologies and AI-Driven Solutions

This white paper examines the potential of pioneering technologies and artificial intelligence-driven solutions in advancing clinical trials involving radiation therapy. As the field of radiation therapy evolves, the integration of cutting-edge approaches such as radiopharmaceutical dosimetry, FLASH radiation therapy, image guided radiation therapy, and artificial intelligence promises to improve treatment planning, patient care, and outcomes. Additionally, recent advancements in quantum science, linear energy transfer/relative biological effect, and the combination of radiation therapy and immunotherapy create new avenues for innovation in clinical trials. The paper aims to provide an overview of these emerging technologies and discuss their challenges and opportunities in shaping the future of radiation oncology clinical trials. By synthesizing knowledge from experts across various disciplines, this white paper aims to present a foundation for the successful integration of these innovations into radiation therapy research and practice, ultimately enhancing patient outcomes and revolutionizing cancer care.

Characterization of commercial detectors for absolute proton UHDR dosimetry on a compact clinical proton synchrocyclotron

BACKGROUND

Modern compact proton synchrocyclotrons can achieve ultra-high dose rates ( ≥ $ \ge $ 40 Gy/s) to support ultra-high-dose-rate (UHDR) preclinical experiments utilizing pencil beam scanning (PBS) protons. Unique to synchrocyclotrons is a pulsed proton time structure as compared to the quasi-continuous nature of other proton accelerators like isochronous cyclotrons. Thus, high instantaneous proton currents in the order of several µA must be generated to achieve UHDRs. This will lead to high doses-per-pulse (DPP), which may cause significant charge recombination for ionization chambers, which must be characterized for accurate UHDR dosimetry programs.

PURPOSE

In this work, we investigate the suitability of various commercial radiation detectors for accurate proton UHDR dosimetry using PBS proton beams from a compact proton synchrocyclotron (IBA ProteusONE). This is achieved by cross-calibrating them with conventional dose rates, measuring UHDR recombination (Pion) and polarity correction factors (Ppol) for ionization chambers, and determining the absorbed proton UHDR dose delivered for all detectors.

METHODS

An IBA ProteusONE synchrocyclotron was initially tuned to achieve UHDRs with 228 MeV protons at 0° gantry angle. Various detectors, including Razor Chamber, Razor Nano Chamber, Razor Diode, and microDiamond, were cross-calibrated against a PPC05 plane-parallel ionization chamber (PPIC) that had an ADCL calibration coefficient of 59.23 cGy/nC. Then, all ionization chambers were exposed to UHDR protons with the Ppol and Pion subsequently calculated. Pion was calculated using two methods: TRS-398 methods and Niatel's model. Finally, the absolute UHDR proton doses delivered were determined for all detectors and cross-compared.

RESULTS

Faraday cup measurements were performed for a single spot proton UHDR beam, and the nozzle current at the isocenter was determined to be 129.5 nA during UHDR irradiations at 98.61% of the maximum theoretical dose rate. Repeated Faraday cup measurements of the UHDR beam yielded a percentage standard deviation of 0.8%, which was higher than 0.120% when similar repeated measurements were performed with conventional proton beams. Ppol was found to be relatively dose-rate independent for all ionization chambers investigated. Pion was found to be the lowest for the PPC05 ionization chamber (1.0097) compared to corresponding values of 1.0214 and 1.0294 for the Razor and Razor Nano detectors, respectively, for UHDRs. Pion values calculated using Niatel's model closely matched values from TRS-398 if the VH/VL ratio were kept at 2.5 for the PPC05 and Razor detectors and 2.0 for the Razor Nano detector. Absolute proton UHDR doses determined using cross-calibration factors were generally within ± 1% of PPC05 measurements. However, Razor Diode was found to over-respond by up to 3.79% within UHDR proton beams, rendering them unsuitable for proton UHDR dosimetry.

CONCLUSION

In this work, we comprehensively evaluated the suitability of various commercial detectors for absolute dosimetry with a pulsed UHDR beam structure from a proton synchrocyclotron. PPC05 had the lowest ionic recombination correction compared to Razor and Razor Nano ion chambers. Other than the diode detector, all other investigated detectors (PPC05, Razor, Razor Nano, microDiamond) were within ± 1% of one another and can be used for accurate absolute proton UHDR dosimetry.

Proton FLASH Irradiation Using a Synchrotron Accelerator: Differences by Irradiation Positions

PURPOSE

To establish an ultra-high dose-rate (UHDR) radiation system using a synchrotron proton beam accelerator and to compare the effects by irradiation positions on cultured cells and chick embryos.

METHODS AND MATERIALS

Protons for UHDR were obtained by applying high-frequency power at much higher levels than usual to extract all protons within approximately 50 ms. Subsequently, monitoring with a Faraday cup was performed immediately after synchrotron extraction and the waveform was adjusted accordingly. Four cultured tumor lines, 2 normal cell lines, and chick embryos were used. UHDR radiation therapy (UHDR-RT) at 6 to 18 Gy (200-300 Gy/s, single exposure) and conventional dose-rate radiation therapy (Conv-RT) at 6 to 18 Gy (3 Gy/s) were administered to the 1-cm spread-out Bragg peak (SOBP) and the plateau region preceding SOBP. After irradiation, disparities in cell growth rates and cell cycle progression were assessed, and cell survival was evaluated via colony assay. Chick embryos were also examined for survival.

RESULTS

UHDR-RT was achieved at a range of 40 to 800 Gy/s, encompassing both plateau and peak phases. In vitro studies demonstrated similar cell-killing effects between UHDR-RT and Conv-RT in cancer cells. Significant apoptotic effects and G2 arrest were observed during the cell cycle under peak UHDR-RT conditions. The FLASH effect was not observed in normal single cells under normal atmospheric conditions. Stronger cell-killing effects were noted in V79 spheroids exposed to peak UHDR-RT than peak Conv-RT. Moreover, in chick embryos, an increase in survival rate, indicative of the FLASH effect, was observed.

CONCLUSIONS

The FLASH effect was also achieved with UHDR-RT using a synchrotron proton beam accelerator in chick embryos. The cell-killing effects in cancer cells were higher with peak UHDR-RT that may be due to the higher linear energy transfer at the SOBP.

Enabling clinical use of linear energy transfer in proton therapy for head and neck cancer - A review of implications for treatment planning and adverse events study

Proton therapy offers significant advantages due to its unique physical and biological properties, particularly the Bragg peak, enabling precise dose delivery to tumors while sparing healthy tissues. However, the clinical implementation is challenged by the oversimplification of the relative biological effectiveness (RBE) as a fixed value of 1.1, which does not account for the complex interplay between dose, linear energy transfer (LET), and biological endpoints. Lack of heterogeneity control or the understanding of the complex interplay may result in unexpected adverse events and suboptimal patient outcomes. On the other hand, expanding our knowledge of variable tumor RBE and LET optimization may provide a better management strategy for radioresistant tumors. This review examines recent advancements in LET calculation methods, including analytical models and Monte Carlo simulations. The integration of LET into plan evaluation is assessed to enhance plan quality control. LET-guided robust optimization demonstrates promise in minimizing high-LET exposure to organs at risk, thereby reducing the risk of adverse events. Dosimetric seed spot analysis is discussed to show its importance in revealing the true LET-related effect upon the adverse event initialization by finding the lesion origins and eliminating the confounding factors from the biological processes. Dose-LET volume histograms (DLVH) are discussed as effective tools for correlating physical dose and LET with clinical outcomes, enabling the derivation of clinically relevant dose-LET volume constraints without reliance on uncertain RBE models. Based on DLVH, the dose-LET volume constraints (DLVC)-guided robust optimization is introduced to upgrade conventional dose-volume constraints-based robust optimization, which optimizes the joint distribution of dose and LET simultaneously. In conclusion, translating the advances in LET-related research into clinical practice necessitates a better understanding of the LET-related biological mechanisms and the development of clinically relevant LET-related volume constraints directly derived from the clinical outcomes. Future research is needed to refine these models and conduct prospective trials to assess the clinical benefits of LET-guided optimization on patient outcomes.

Biological dose-based fractional dose optimization of Bragg peak FLASH-RT for lung cancer treatment

BACKGROUND

The FLASH effect is dose-dependent, and fractional dose optimization may enhance it, improving normal tissue sparing.

PURPOSE

This study investigates the performance of fractional dose optimization in enhancing normal tissue sparing for Bragg peak FLASH radiotherapy (FLASH-RT).

METHODS

15 lung cancer patients, including eight with peripherally located tumors and seven with centrally located tumors, were retrospectively analyzed. A uniform fractionation prescription of 50 Gy in five fractions was utilized, corresponding to a biological equivalent dose (BED) of 100 Gy, calculated using an α/β value of 10 Gy. For each patient, uniform (UFD) and nonuniform fractional dose (non-UFD) plans were designed. In UFD FLASH plans, five multi-energy Bragg peak beams were optimized using single-field optimization, each delivering 10 Gy to the target. In non-UFD FLASH plans, fractional doses were optimized to enhance sparing effects while ensuring the target received a BED comparable to UFD plans. A dose-dependent FLASH enhancement ratio (FER) was integrated with the BED to form the FER-BED metric to compare the UFD and non-UFD plans. An α/β value of 3 Gy was applied for normal tissues in the calculations.

RESULTS

Bragg peak FLASH plans showed high dose conformality for both peripheral and central tumors, with all plans achieving a conformality index (the ratio of the volume receiving the prescribed dose to the CTV volume) below 1.2. In non-UFD plans, fractional doses ranged from 5.0 Gy to 20.0 Gy. Compared to UFD plans, non-UFD plans achieved similar BED coverage (BED98%: 96.6 Gy vs. 97.1 Gy, p = 0.256), while offering improved organ-at-risk sparing. Specifically, the FER-BED15cc for the heart reduced by 10.5% (9.4 Gy vs. 10.5 Gy, p = 0.017) and the V6.7GyFER-BED for the ipsilateral lung decreased by 4.3% (29 .1% vs. 30.4%, p = 0.008). No significant difference was observed in FER-BED0.25cc of spinal cord (UFD: 7.1 Gy, non-UFD: 6.9 Gy, p = 0.626) and FER-BED5cc in esophagus (UFD: 0.4 Gy, non-UFD: 0.4 Gy, p = 0.831).

CONCLUSIONS

Bragg peak FLASH-RT achieved high dose conformality for both peripheral and central tumors. Fractional dose optimization, using a single beam per fraction delivery mode, enhanced normal tissue sparing by leveraging both fractionation and FLASH effects.

FLASH radiotherapy combined with immunotherapy: From biological mechanisms to blockbuster therapeutics

FLASH ultra-high dose rate radiotherapy (RT) can effectively exert the protective effect on normal tissue and reduce the risk of treatment-related toxicity, without compromising the killing effect on tumor tissue, resulting in a significant differential biological effect between tumor control and normal tissue damage, namely the FLASH effect. To date, the precise biological details of the FLASH effect remain uncertain. The currently mainstream mechanisms proposed by the academic community include the transient oxygen depletion hypothesis, free radical hypothesis, immune protection hypothesis, and DNA integrity hypothesis, which have attracted increasing attention in recent years. Based on these theoretical principles and numerous investigations on the FLASH effect in vivo and in vitro, the combined application of FLASH and immune checkpoint inhibitors (ICIs) has been considered synergistic and potentially practical. The primary underlying basis is that FLASH might actively preserve the number and function of circulating immune cells, thereby enhancing the efficacy of immune cell-mediated immunotherapy. Meanwhile, FLASH RT could activate the tumor immune microenvironment and transform "cold'' tumors into ''hot'' ones, consequently boosting local and systemic anti-tumor immunity and expanding the therapeutic benefits of ICIs. Moreover, FLASH might attenuate immunoinflammatory responses and minimize the incidence of radiation-related adverse events, allowing for the potentially safer and promising clinical application of combing FLASH RT with ICI therapy. Nevertheless, data on this treatment modality is currently lacking, and several barriers remain to be addressed, including the logistical bottlenecks, technical hurdles, limited availability, and unclear biological mechanisms. Further research is warranted in the future.

Feasibility study of modularized pin ridge filter implementation in proton FLASH planning for liver stereotactic ablative body radiotherapy

Objective.We previously developed a FLASH planning framework for streamlined pin-ridge-filter (pin-RF) design, demonstrating its feasibility for single-energy proton FLASH planning. In this study, we refined the pin-RF design for easy assembly using reusable modules, focusing on its application in liver stereotactic ablative body radiotherapy (SABR).Approach.This framework generates an intermediate intensity-modulated proton therapy (IMPT) plan and translates it into step widths and thicknesses of pin-RFs for a single-energy FLASH plan. Parameters like energy spacing, monitor unit limit, and spot quantity were adjusted during IMPT planning, resulting in pin-RFs assembled using predefined modules with widths from 1 to 6 mm, each with a water-equivalent-thickness of 5 mm. This approach was validated on three liver SABR cases. FLASH doses, quantified using the FLASH effectiveness model at 1-5 Gy thresholds, were compared to conventional IMPT (IMPT-CONV) doses to assess clinical benefits.Main results.The highest demand for 6 mm width modules, moderate for 2-4 mm, and minimal for 1- and 5-mm modules were shown across all cases. At lower dose thresholds, the two-beam case reduced indicators including liverV21Gyand skinDmaxby >19.4%, while the three-beam cases showed reductions⩽11.4%, indicating the need for higher fractional beam doses for an enhanced FLASH effect. Positive clinical benefits were seen only in the two-beam case at the 5 Gy threshold. At the 1 Gy threshold, the two-beam FLASH plan outperformed the IMPT-CONV plan, reducing dose indicators for all relevant normal tissues by up to 31.2%. In contrast, the three-beam cases showed negative clinical benefits, with skinDmaxand liverV21Gyincreasing by up to 17.4% due to lower fractional beam doses and closer beam arrangements.Significance.This study evaluated the feasibility of modularizing streamlined pin-RFs in single-energy proton FLASH planning for liver SABR, offering guidance on optimal module composition and strategies to enhance FLASH planning.

Characterizing devices for validation of dose, dose rate, and LET in ultra high dose rate proton irradiations

BACKGROUND

Ultra high dose rate (UHDR) radiotherapy using ridge filter is a new treatment modality known as conformal FLASH that, when optimized for dose, dose rate (DR), and linear energy transfer (LET), has the potential to reduce damage to healthy tissue without sacrificing tumor killing efficacy via the FLASH effect.

PURPOSE

Clinical implementation of conformal FLASH proton therapy has been limited by quality assurance (QA) challenges, which include direct measurement of UHDR and LET. Voxel DR distributions and LET spectra at planning target margins are paramount to the DR/LET-related sparing of organs at risk. We hereby present a methodology to achieve experimental validation of these parameters.

METHODS

Dose, DR, and LET were measured for a conformal FLASH treatment plan involving a 250-MeV proton beam and a 3D-printed ridge filter designed to uniformly irradiate a spherical target. We measured dose and DR simultaneously using a 4D multi-layer strip ionization chamber (MLSIC) under UHDR conditions. Additionally, we developed an "under-sample and recover (USRe)" technique for a high-resolution pixelated semiconductor detector, Timepix3, to avoid event pile-up and to correct measured LET at high-proton-flux locations without undesirable beam modifications. Confirmation of these measurements was done using a MatriXX PT detector and by Monte Carlo (MC) simulations.

RESULTS

MC conformal FLASH computed doses had gamma passing rates of >95% (3 mm/3% criteria) when compared to MatriXX PT and MLSIC data. At the lateral margin, DR showed average agreement values within 0.3% of simulation at 100 Gy/s and fluctuations ∼10% at 15 Gy/s. LET spectra in the proximal, lateral, and distal margins had Bhattacharyya distances of <1.3%.

CONCLUSION

Our measurements with the MLSIC and Timepix3 detectors shown that the DR distributions for UHDR scenarios and LET spectra using USRe are in agreement with simulations. These results demonstrate that the methodology presented here can be used effectively for the experimental validation and QA of FLASH treatment plans.

A Fast 3D Range-Modulator Delivery Approach: Validation of the FLUKA Model on a Varian ProBeam System Including a Robustness Analysis

A 3D range-modulator (RM), optimized for a single energy and a specific target shape, is a promising and viable solution for the ultra-fast dose delivery in particle therapy. The aim of this work was to investigate the impact of potential beam and modulator misalignments on the dose distribution. Moreover, the FLUKA Monte Carlo model, capable of simulating 3D RMs, was adjusted and validated for the 250 MeV single-energy proton irradiation from a Varian ProBeam system. A 3D RM was designed for a cube target shape rotated 45° around two axes using a Varian-internal research version of the Eclipse treatment planning software, and the resulting dose distribution was simulated in a water phantom. Deviations from the ideal alignment were introduced, and the dose distributions from the modified simulations were compared to the original unmodified one. Finally, the FLUKA model and the workflow were validated with base-line data measurements and dose measurements of the manufactured modulator prototype at the HollandPTC facility in Delft. The adjusted FLUKA model, optimized particularly in the scope of a single-energy FLASH irradiation with a PMMA pre-absorber, demonstrated very good agreement with the measured dose distribution resulting from the 3D RM. Dose deviations resulting from modulator-beam axis misalignments depend on the specific 3D RM and its shape, pin aspect ratio, rotation angle, rotation point, etc. A minor modulator shift was found to be more relevant for the distal dose distribution than for the spread-out Bragg Peak (SOBP) homogeneity. On the other hand, a modulator tilt (rotation away from the beam axis) substantially affected not only the depth dose profile, transforming a flat SOBP into a broad, Gaussian-like distribution with increasing rotation angle, but also shifted the lateral dose distribution considerably. This work strives to increase awareness and highlight potential pitfalls as the 3D RM method progresses from a purely research concept to pre-clinical studies and human trials. Ensuring that gantry rotation and the combined weight of RM, PMMA, and aperture do not introduce alignment issues is critical. Given all the other range and positioning uncertainties, etc., not related to the modulator, the RM must be aligned with an accuracy below 1° in order to preserve a clinically acceptable total uncertainty budget. Careful consideration of critical parameters like the pin aspect ratio and possibly a novel robust modulator geometry optimization are potential additional strategies to mitigate the impact of positioning on the resulting dose. Finally, even the rotated cube 3D modulator with high aspect ratio pin structures (~80 mm height to 3 mm pin base width) was found to be relatively robust against a slight misalignment of 0.5° rotation or a 1.5 mm shift in one dimension perpendicular to the beam axis. Given a reliable positioning and QA concept, the additional uncertainties introduced by the 3D RM can be successfully managed adopting the concept into the clinical routine.

A multidisciplinary view of flash irradiation

The delivery of ultra-high dose rates of radiation, called flash irradiation or flash-RT, has emerged as a new modality of radiotherapy shaking up the paradigm of proportionality of effect and dose whatever the method of delivery of the radiation. The hallmark of flash-RT is healthy tissue sparing from the side effects of radiation without decrease of the antitumor efficiency in animal models. In this review we will define its specificities, the molecular mechanisms underlying the flash effect and the ongoing developments to bring this new modality to patient treatment.

Fractionation dose optimization facilities the implementation of transmission proton FLASH-RT

Objective.The beam switching time and fractional dose influence the FLASH effect. A single-beam-per-fraction (SBPF) scheme using uniform fractional dose (UFD) has been proposed for FLASH- radiotherapy (FLASH-RT) to eliminate the beam switching time. Based on SBPF schemes, a fractionation dose optimization algorithm is proposed to optimize non-UFD plans to maximize the fractionation effect and dose-dependent FLASH effect.Approach.The UFD plan, containing five 236 MeV transmission proton beams, was optimized for 11 patients with peripheral lung cancer, with each beam delivering a uniform dose of 11 Gy to the target. Meanwhile, the non-UFD plan was optimized using fractionation dose optimization. To compare the two plans, the equivalent dose to 2 Gy (EQD2) for the target and normal tissues was calculated with anα/βratio of 10 and 3, respectively. Both UFD and non-UFD plans ensured that the target received an EQD2 of 96.3 Gy. To investigate the overall improvement in normal tissue sparing with the non-UFD plan, the FLASH-enhanced EQD2 was calculated.Main results.The fractional doses in non-UFD plans ranged between 5.0 Gy and 24.2 Gy. No significant differences were found in EQD22%and EQD298%of targets between UFD and non-UFD plans. However, theD95%of the target in non-UFD plans was significantly reduced by 15.1%. The sparing effect in non-UFD plans was significantly improved. The FLASH-enhanced EQD2meanin normal tissue and ipsilateral lung was significantly reduced by 3.5% and 10.4%, respectively, in non-UFD plans. The overall improvement is attributed to both the FLASH and fractionation effects.Significance.The fractionation dose optimization can address the limitation of multiple-beam FLASH-RT and utilize the relationship between fractional dose and FLASH effect. Consequently, the non-UFD scheme results in further improvements in normal tissue sparing compared to the UFD scheme, attributed to enhanced fractionation and FLASH effects.

Biological-equivalent-dose-based integrated optimization framework for fast-energy-switching Bragg peak FLASH-RT using single-beam-per-fraction

BACKGROUNDS

When comparing the delivery of all beams per fraction (ABPF) to single beam per fraction (SBPF), it is observed that SBPF not only helps meet the FLASH dose threshold but also mitigates the uncertainty with beam switching in the FLASH effect. However, SBPF might lead to a higher biological equivalent dose in 2 Gy (EQD2) for normal tissues.

PURPOSE

This study aims to develop an EQD2-based integrated optimization framework (EQD2-IOF), encompassing robust dose, delivery efficiency, and beam orientation optimization (BOO) for Bragg peak FLASH plans using the SBPF treatment schedule. The EQD2-IOF aims to enhance both dose sparing and the FLASH effect.

METHODS

A superconducting gantry was employed for fast energy switching within 27 ms, while universal range shifters were utilized to improve beam current in the implementation of FLASH plans with five Bragg peak beams. To enhance dose delivery efficiency while maintaining plan quality, a simultaneous dose and spot map optimization (SDSMO) algorithm for single field optimization was incorporated into a Bayesian optimization-based auto-planning algorithm. Subsequently, a BOO algorithm based on Tabu search was developed to select beam angle combinations (BACs) for 10 lung cases. To simultaneously consider dose sparing and FLASH effect, a quantitative model based on dose-dependent dose modification factor (DMF) was used to calculate FLASH-enhanced dose distribution. The EQD2-IOF plan was compared to the plan optimized without SDSMO using BAC selected by a medical physicist (Manual plan) in the SBPF treatment schedule. Meanwhile, the mean EQD2 in the normal tissue was evaluated for the EQD2-IOF plan in both SBPF and ABPF treatment schedules.

RESULTS

No significant difference was found in D2% and D98% of the target between EQD2-IOF plans and Manual Plans. When using a minimum DMF of 0.67 and a dose threshold of 4 Gy, EQD2-IOF plans showed a significant reduction in FLASH-enhanced EQD2mean of the ipsilateral lung and normal tissue by 10.5% and 11.5%, respectively, compared to Manual plans. For normal tissues that received a dose greater than 70% of the prescription dose, using a minimum DMF of 0.7 for FLASH sparing compensated for the increase in EQD2mean resulting from replacing ABPF with SBPF schedules.

CONCLUSIONS

The EQD2-IOF can automatically optimize SBPF FLASH-RT plans to achieve optimal sparing of normal tissues. With an energy switching time of 27 ms, the loss of fractionate repairing using SBPF schedules in high-dose regions can be compensated for by the FLASH effect. However, when an energy switching time of 500 ms is utilized, the SBPF schedule needs careful consideration, as the FLASH effect diminishes with longer irradiation time.

Optimal minimum MU for intensity-modulated proton therapy with pencil-beam scanning proton beams

PURPOSE

A higher minimum monitor unit (minMU) for pencil-beam scanning proton beams in intensity-modulated proton therapy is preferred for more efficient delivery. However, plan quality may be compromised when the minMU is too large. This study aimed to identify the optimal minMU (OminMU) to improve plan delivery efficiency while maintaining high plan quality.

METHODS

We utilized clinical plans including six anatomic sites (brain, head and neck, breast, lung, abdomen, and prostate) from 23 patients previously treated with the Varian ProBeam system. The minMU of each plan was increased from the current clinical minMU of 1.1 to 3-24 MU depending on the daily prescribed dose (DPD). The dosimetric parameters of the plans were evaluated for consistency against a 1.1-minMU plan for target coverage as well as organs-at-risk dose sparing. DPD/minMU was defined as the ratio of DPD to minMU (cGy/MU) to find the OminMU by ensuring that dosimetric parameters did not differ by >1% compared to those of the 1.1-minMU plan.

RESULTS

All plans up to 5 minMU showed no significant dose differences compared to the 1.1-minMU plan. Plan qualities remained acceptable when DPD/minMU ≥35 cGy/MU. This suggests that the 35 cGy/MU criterion can be used as the OminMU, which implies that 5 MU is the OminMU for a conventional fraction dose of 180 cGy. Treatment times were decreased by an average of 32% (max 56%, min 7%) and by an average of 1.6 min when the minMU was increased from 1.1 to OminMU.

CONCLUSION

A clinical guideline for OminMU has been established. The minMU can be increased by 1 MU for every 35 cGy of DPD without compromising plan quality for most cases analyzed in this study. Significant treatment time reduction of up to 56% was observed when the suggested OminMU is used.

NRG Oncology and Particle Therapy Co-Operative Group Patterns of Practice Survey and Consensus Recommendations on Pencil-Beam Scanning Proton Stereotactic Body Radiation Therapy and Hypofractionated Radiation Therapy for Thoracic Malignancies

Stereotactic body radiation therapy (SBRT) and hypofractionation using pencil-beam scanning (PBS) proton therapy (PBSPT) is an attractive option for thoracic malignancies. Combining the advantages of target coverage conformity and critical organ sparing from both PBSPT and SBRT, this new delivery technique has great potential to improve the therapeutic ratio, particularly for tumors near critical organs. Safe and effective implementation of PBSPT SBRT/hypofractionation to treat thoracic malignancies is more challenging than the conventionally fractionated PBSPT because of concerns of amplified uncertainties at the larger dose per fraction. The NRG Oncology and Particle Therapy Cooperative Group Thoracic Subcommittee surveyed proton centers in the United States to identify practice patterns of thoracic PBSPT SBRT/hypofractionation. From these patterns, we present recommendations for future technical development of proton SBRT/hypofractionation for thoracic treatment. Among other points, the recommendations highlight the need for volumetric image guidance and multiple computed tomography-based robust optimization and robustness tools to minimize further the effect of uncertainties associated with respiratory motion. Advances in direct motion analysis techniques are urgently needed to supplement current motion management techniques.

Navigating the straits: realizing the potential of proton FLASH through physics advances and further pre-clinical characterization

Ultra-high dose-rate 'FLASH' radiotherapy may be a pivotal step forward for cancer treatment, widening the therapeutic window between radiation tumour killing and damage to neighbouring normal tissues. The extent of normal tissue sparing reported in pre-clinical FLASH studies typically corresponds to an increase in isotoxic dose-levels of 5-20%, though gains are larger at higher doses. Conditions currently thought necessary for FLASH normal tissue sparing are a dose-rate ≥40 Gy s-1, dose-per-fraction ≥5-10 Gy and irradiation duration ≤0.2-0.5 s. Cyclotron proton accelerators are the first clinical systems to be adapted to irradiate deep-seated tumours at FLASH dose-rates, but even using these machines it is challenging to meet the FLASH conditions. In this review we describe the challenges for delivering FLASH proton beam therapy, the compromises that ensue if these challenges are not addressed, and resulting dosimetric losses. Some of these losses are on the same scale as the gains from FLASH found pre-clinically. We therefore conclude that for FLASH to succeed clinically the challenges must be systematically overcome rather than accommodated, and we survey physical and pre-clinical routes for achieving this.

Creating uniform cluster dose spread-out Bragg peaks for proton and carbon beams

BACKGROUND

Preliminary data have shown a close association of the generalized ionization cluster size dose (in short, cluster dose) with cell survival, independent of particle type, and energy, when cluster dose is derived from an ionization detail parameter preferred for its association with cell survival. Such results suggest cluster dose has the potential to replace RBE-weighted dose in proton and ion beam radiotherapy treatment plan optimization, should a uniform cluster dose lead to comparable biological effects. However, further preclinical investigations are warranted to confirm this premise.

PURPOSE

To present an analytical approach to create uniform cluster dose spread-out Bragg peaks (SOBP) for evaluation of the potential of cluster dose to result in uniform biological effect.

METHODS

We modified the coefficients of the Bortfeld and Schlegel weight formula, an analytical method typically used for the creation of radiation dose SOBP in particle therapy, to produce uniform cluster dose SOBP of different widths (1-5 cm) at relevant clinical proton and carbon beam energies. Optimum parameters were found by minimization of the ratio between the maximum and minimum cluster dose in the SOBP region using the Nelder-Mead method.

RESULTS

The coefficients of the Bortfeld and Schlegel weight formula leading to uniform cluster dose SOBPs were determined for each combination of beam energy and SOBP width studied. The uniformity of the resulting cluster dose SOBPs, calculated as the relative difference between the maximum and minimum cluster dose within the SOBP, was within 0.3%-3.5% for the evaluated proton beams and 1.3%-3.4% for the evaluated carbon beams.

CONCLUSIONS

The modifications to the analytical approach to create radiation dose SOBPs resulted in uniform cluster dose proton and carbon SOBPs over a wide range of beam energies and SOBP widths. Such SOBPs should prove valuable in preclinical investigations for the selection of nanodosimetric quantities to be used in proton and ion therapy treatment planning.

Mixed-size spot scanning with a compact large momentum acceptance superconducting (LMA-SC) gantry beamline for proton therapy

Objective. Lowering treatment costs and improving treatment quality are two primary goals for next-generation proton therapy (PT) facilities. This work will design a compact large momentum acceptance superconducting (LMA-SC) gantry beamline to reduce the footprint and expense of the PT facilities, with a novel mixed-size spot scanning method to improve the sparing of organs at risk (OAR).Approach. For the LMA-SC gantry beamline, the movable energy slit is placed in the middle of the last achromatic bending section, and the beam momentum spread of delivered spots can be easily changed during the treatment. Simultaneously, changing the collimator size can provide spots with various lateral spot sizes. Based on the provided large-size and small-size spot models, the treatment planning with mixed spot scanning is optimized: the interior of the target is irradiated with large-size spots (to cover the uniform-dose interior efficiently), while the peripheral of the target is irradiated with small-size spots (to shape the sharp dose falloff at the peripheral accurately).Main results. The treatment plan with mixed-size spot scanning was evaluated and compared with small and large-size spot scanning for thirteen clinical prostate cases. The mixed-size spot plan had superior target dose homogeneities, better protection of OAR, and better plan robustness than the large-size spot plan. Compared to the small-size spot plan, the mixed-size spot plan had comparable plan quality, better plan robustness, and reduced plan delivery time from 65.9 to 40.0 s.Significance. The compact LMA-SC gantry beamline is proposed with mixed-size spot scanning, with demonstrated footprint reduction and improved plan quality compared to the conventional spot scanning method.

Streamlined pin-ridge-filter design for single-energy proton FLASH planning

BACKGROUND

FLASH radiotherapy (FLASH-RT) with ultra-high dose rate has yielded promising results in reducing normal tissue toxicity while maintaining tumor control. Planning with single-energy proton beams modulated by ridge filters (RFs) has been demonstrated feasible for FLASH-RT.

PURPOSE

This study explored the feasibility of a streamlined pin-shaped RF (pin-RF) design, characterized by coarse resolution and sparsely distributed ridge pins, for single-energy proton FLASH planning.

METHODS

An inverse planning framework integrated within a treatment planning system was established to design streamlined pin RFs for single-energy FLASH planning. The framework involves generating a multi-energy proton beam plan using intensity-modulated proton therapy (IMPT) planning based on downstream energy modulation strategy (IMPT-DS), followed by a nested pencil-beam-direction-based (PBD-based) spot reduction process to iteratively reduce the total number of PBDs and energy layers along each PBD for the IMPT-DS plan. The IMPT-DS plan is then translated into the pin-RFs and the single-energy beam configurations for IMPT planning with pin-RFs (IMPT-RF). This framework was validated on three lung cases, quantifying the FLASH dose of the IMPT-RF plan using the FLASH effectiveness model. The FLASH dose was then compared to the reference dose of a conventional IMPT plan to measure the clinical benefit of the FLASH planning technique.

RESULTS

The IMPT-RF plans closely matched the corresponding IMPT-DS plans in high dose conformity (conformity index of <1.2), with minimal changes in V7Gy and V7.4 Gy for the lung (<3%) and small increases in maximum doses (Dmax) for other normal structures (<3.4 Gy). Comparing the FLASH doses to the doses of corresponding IMPT-RF plans, drastic reductions of up to nearly 33% were observed in Dmax for the normal structures situated in the high-to-moderate-dose regions, while negligible changes were found in Dmax for normal structures in low-dose regions. Positive clinical benefits were seen in comparing the FLASH doses to the reference doses, with notable reductions of 21.4%-33.0% in Dmax for healthy tissues in the high-dose regions. However, in the moderate-to-low-dose regions, only marginal positive or even negative clinical benefit for normal tissues were observed, such as increased lung V7Gy and V7.4 Gy (up to 17.6%).

CONCLUSIONS

A streamlined pin-RF design was developed and its effectiveness for single-energy proton FLASH planning was validated, revealing positive clinical benefits for the normal tissues in the high dose regions. The coarsened design of the pin-RF demonstrates potential advantages, including cost efficiency and ease of adjustability, making it a promising option for efficient production.

Feasibility study of multiple-energy Bragg peak proton FLASH on a superconducting gantry with large momentum acceptance

BACKGROUND

While the Bragg peak proton beam (BP) is capable of superior target conformity and organs-at-risk sparing than the transmission proton beam (TB), its efficacy in FLASH-RT is hindered by both a slow energy switching process and the beam current. A universal range shifter (URS) can pull back the high-energy proton beam while preserving the beam current. Meanwhile, a superconducting gantry with large momentum acceptance (LMA-SC gantry) enables fast energy switching.

PURPOSE

This study explores the feasibility of multiple-energy BP FLASH-RT on the LMA-SC gantry.

METHOD AND MATERIALS

A simultaneous dose and spot map optimization algorithm was developed for BP FLASH-RT treatment planning to improve the dose delivery efficiency. The URS was designed to be 0-27 cm thick, with 1 cm per step. BP plans using the URS were optimized using single-field optimization (SFO) and multiple-field optimization (MFO) for ten prostate cancer patients and ten lung cancer patients. The plan delivery parameters, dose, and dose rate metrics of BP plans were compared to those of TB plans using the parameters of the LMA-SC gantry.

RESULTS

Compared to TB plans, BP plans significantly reduced MUs by 42.7% (P < 0.001) with SFO and 33.3% (P < 0.001) with MFO for prostate cases. For lung cases, the reduction in MUs was 56.8% (P < 0.001) with SFO and 36.4% (P < 0.001) with MFO. BP plans also outperformed TB plans by reducing mean normal tissue doses. BP-SFO plans achieved a reduction of 56.7% (P < 0.001) for prostate cases and 57.7% (P < 0.001) for lung cases, while BP-MFO plans achieved a reduction of 54.2% (P < 0.001) for the prostate case and 40.0% (P < 0.001) for lung cases. For both TB and BP plans, normal tissues in prostate and lung cases received 100.0% FLASH dose rate coverage (>40 Gy/s).

CONCLUSIONS

By utilizing the URS and the LMA-SC gantry, it is possible to perform multiple-energy BP FLASH-RT, resulting in better normal tissue sparing, as compared to TB plans.

Development and benchmarking of a dose rate engine for raster-scanned FLASH helium ions

BACKGROUND

Radiotherapy with charged particles at high dose and ultra-high dose rate (uHDR) is a promising technique to further increase the therapeutic index of patient treatments. Dose rate is a key quantity to predict the so-called FLASH effect at uHDR settings. However, recent works introduced varying calculation models to report dose rate, which is susceptible to the delivery method, scanning path (in active beam delivery) and beam intensity.

PURPOSE

This work introduces an analytical dose rate calculation engine for raster scanned charged particle beams that is able to predict dose rate from the irradiation plan and recorded beam intensity. The importance of standardized dose rate calculation methods is explored here.

METHODS

Dose is obtained with an analytical pencil beam algorithm, using pre-calculated databases for integrated depth dose distributions and lateral penumbra. Dose rate is then calculated by combining dose information with the respective particle fluence (i.e., time information) using three dose-rate-calculation models (mean, instantaneous, and threshold-based). Dose rate predictions for all three models are compared to uHDR helium ion beam (145.7 MeV/u, range in water of approximatively 14.6 cm) measurements performed at the Heidelberg Ion Beam Therapy Center (HIT) with a diamond-detector prototype. Three scanning patterns (scanned or snake-like) and four field sizes are used to investigate the dose rate differences.

RESULTS

Dose rate measurements were in good agreement with in-silico generated distributions using the here introduced engine. Relative differences in dose rate were below 10% for varying depths in water, from 2.3 to 14.8 cm, as well as laterally in a near Bragg peak area. In the entrance channel of the helium ion beam, dose rates were predicted within 7% on average for varying irradiated field sizes and scanning patterns. Large differences in absolute dose rate values were observed for varying calculation methods. For raster-scanned irradiations, the deviation between mean and threshold-based dose rate at the investigated point was found to increase with the field size up to 63% for a 10 mm × 10 mm field, while no significant differences were observed for snake-like scanning paths.

CONCLUSIONS

This work introduces the first dose rate calculation engine benchmarked to instantaneous dose rate, enabling dose rate predictions for physical and biophysical experiments. Dose rate is greatly affected by varying particle fluence, scanning path, and calculation method, highlighting the need for a consensus among the FLASH community on how to calculate and report dose rate in the future. The here introduced engine could help provide the necessary details for the analysis of the sparing effect and uHDR conditions.

FLASH radiotherapy sparing effect on the circulating lymphocytes in pencil beam scanning proton therapy: impact of hypofractionation and dose rate

Purpose. The sparing effect of ultra-high dose rate (FLASH) radiotherapy has been reported, but its potential to mitigate depletion of circulating blood and lymphocytes (CL) has not been investigated in pencil-beam scanning-based (PBS) proton therapy, which could potentially reduce the risk of radiation-induced lymphopenia.Material and methods. A time-dependent framework was used to score the dose to the CL during the course of radiotherapy. For brain patients, cerebral vasculatures were semi-automatic segmented from 3T MR-angiography data. A dynamic beam delivery system was developed capable of simulating spatially varying instantaneous dose rates of PBS treatment plans, and which is based on realistic beam delivery parameters that are available clinically. We simulated single and different hypofractionated PBS intensity modulated proton therapy (IMPT) FLASH schemes using 600 nA beam current along with conventionally fractionated IMPT treatment plan at 2 nA beam current. The dosimetric impact of treatment schemes on CL was quantified, and we also evaluated the depletion in subsets of CL based on their radiosensitivity.Results. The proton FLASH sparing effect on CL was observed. In single-fraction PBS FLASH, just 1.5% of peripheral blood was irradiated, whereas hypofractionated FLASH irradiated 7.3% of peripheral blood. In contrast, conventional fractionated IMPT exposed 42.4% of peripheral blood to radiation. PBS FLASH reduced the depletion rate of CL by 69.2% when compared to conventional fractionated IMPT.Conclusion. Our dosimetric blood flow model provides quantitative measures of the PBS FLASH sparing effect on the CL in radiotherapy for brain cancer. FLASH Single treatment fraction offers superior CL sparing when compared to hypofractionated FLASH and conventional IMPT, supporting assumptions about reducing risks of lymphopenia compared to proton therapy at conventional dose rates. The results also indicate that faster conformal FLASH delivery, such as passive patient-specific energy modulation, may further enhance the sparing of the immune system.

Superiorization of projection algorithms for linearly constrained inverse radiotherapy treatment planning

Objective

We apply the superiorization methodology to the constrained intensity-modulated radiation therapy (IMRT) treatment planning problem. Superiorization combines a feasibility-seeking projection algorithm with objective function reduction: The underlying projection algorithm is perturbed with gradient descent steps to steer the algorithm towards a solution with a lower objective function value compared to one obtained solely through feasibility-seeking.

Approach

Within the open-source inverse planning toolkit matRad, we implement a prototypical algorithmic framework for superiorization using the well-established Agmon, Motzkin, and Schoenberg (AMS) feasibility-seeking projection algorithm and common nonlinear dose optimization objective functions. Based on this prototype, we apply superiorization to intensity-modulated radiation therapy treatment planning and compare it with (i) bare feasibility-seeking (i.e., without any objective function) and (ii) nonlinear constrained optimization using first-order derivatives. For these comparisons, we use the TG119 water phantom, the head-and-neck and the prostate patient of the CORT dataset.

Main results

Bare feasibility-seeking with AMS confirms previous studies, showing it can find solutions that are nearly equivalent to those found by the established piece-wise least-squares optimization approach. The superiorization prototype solved the linearly constrained planning problem with similar dosimetric performance to that of a general-purpose nonlinear constrained optimizer while showing smooth convergence in both constraint proximity and objective function reduction.

Significance

Superiorization is a useful alternative to constrained optimization in radiotherapy inverse treatment planning. Future extensions with other approaches to feasibility-seeking, e.g., with dose-volume constraints and more sophisticated perturbations, may unlock its full potential for high performant inverse treatment planning.

Definition of dose rate for FLASH pencil-beam scanning proton therapy: A comparative study

BACKGROUND

FLASH proton therapy has the potential to reduce side effects of conventional proton therapy by delivering a high dose of radiation in a very short period of time. However, significant progress is needed in the development of FLASH proton therapy. Increasing the dose rate while maintaining dose conformality may involve the use of advanced beam-shaping technologies and specialized equipment such as 3D patient-specific range modulators, to take advantage of the higher transmission efficiency at the highest energy available. The dose rate is an important factor in FLASH proton therapy, but its definition can vary because of the uneven distribution of the dose over time in pencil-beam scanning (PBS).

PURPOSE

Highlight the distinctions, both in terms of concept and numerical values, of the various definitions that can be established for the dose rate in PBS proton therapy.

METHODS

In an in silico study, five definitions of the dose rate, namely the PBS dose rate, the percentile dose rate, the maximum percentile dose rate, the average dose rate, and the dose averaged dose rate (DADR) were analyzed first through theoretical comparison, and then applied to a head and neck case. To carry out this study, a treatment plan utilizing a single energy level and requiring the use of a patient-specific range modulator was employed. The dose rate values were compared both locally and by means of dose rate volume histograms (DRVHs).

RESULTS

The PBS dose rate, the percentile dose rate, and the maximum percentile dose are definitions that are specifically designed to take into account the time structure of the delivery of a PBS treatment plan. Although they may appear similar, our study shows that they can vary locally by up to 10%. On the other hand, the DADR values were approximately twice as high as those of the PBS, percentile, and maximum percentile dose rates, since the DADR disregards the periods when a voxel does not receive any dose. Finally, the average dose rate can be defined in various ways, as discussed in this paper. The average dose rate is found to be lower by a factor of approximately 1/2 than the PBS, percentile, and maximum percentile dose rates.

CONCLUSIONS

We have shown that using different definitions for the dose rate in FLASH proton therapy can lead to variations in calculated values ranging from a few percent to a factor of two. Since the dose rate is a critical parameter in FLASH radiation therapy, it is essential to carefully consider the choice of definition. However, to make an informed decision, additional biological data and models are needed.

Proton Bragg Peak FLASH Enables Organ Sparing and Ultra-High Dose-Rate Delivery: Proof of Principle in Recurrent Head and Neck Cancer

Proton pencil-beam scanning (PBS) Bragg peak FLASH combines ultra-high dose rate delivery and organ-at-risk (OAR) sparing. This proof-of-principle study compared dosimetry and dose rate coverage between PBS Bragg peak FLASH and PBS transmission FLASH in head and neck reirradiation. PBS Bragg peak FLASH plans were created via the highest beam single energy, range shifter, and range compensator, and were compared to PBS transmission FLASH plans for 6 GyE/fraction and 10 GyE/fraction in eight recurrent head and neck patients originally treated with quad shot reirradiation (14.8/3.7 CGE). The 6 GyE/fraction and 10 GyE/fraction plans were also created using conventional-rate intensity-modulated proton therapy techniques. PBS Bragg peak FLASH, PBS transmission FLASH, and conventional plans were compared for OAR sparing, FLASH dose rate coverage, and target coverage. All FLASH OAR V40 Gy/s dose rate coverage was 90-100% at 6 GyE and 10 GyE for both FLASH modalities. PBS Bragg peak FLASH generated dose volume histograms (DVHs) like those of conventional therapy and demonstrated improved OAR dose sparing over PBS transmission FLASH. All the modalities had similar CTV coverage. PBS Bragg peak FLASH can deliver conformal, ultra-high dose rate FLASH with a two-millisecond delivery of the minimum MU per spot. PBS Bragg peak FLASH demonstrated similar dose rate coverage to PBS transmission FLASH with improved OAR dose-sparing, which was more pronounced in the 10 GyE/fraction than in the 6 GyE/fraction. This feasibility study generates hypotheses for the benefits of FLASH in head and neck reirradiation and developing biological models.