Dosimetric feasibility of real-time MRI-guided proton therapy

The impact of motion on onboard MRI-guided pencil beam scanned proton therapy treatments

Objective.Online magnetic resonance imaging (MRI) guidance could be especially beneficial for pencil beam scanned (PBS) proton therapy of tumours affected by respiratory motion. For the first time to our knowledge, we investigate the dosimetric impact of respiratory motion on MRI-guided proton therapy compared to the scenario without magnetic field.Approach.A previously developed analytical proton dose calculation algorithm accounting for perpendicular magnetic fields was extended to enable 4D dose calculations. For two geometrical phantoms and three liver and two lung patient cases, static treatment plans were optimised with and without magnetic field (0, 0.5 and 1.5 T). Furthermore, plans were optimised using gantry angle corrections (0.5 T +5° and 1.5 T +15°) to reproduce similar beam trajectories compared to the 0 T reference plans. The effect of motion was then considered using 4D dose calculations without any motion mitigation and simulating 8-times volumetric rescanning, with motion for the patient cases provided by 4DCT(MRI) data sets. Each 4D dose calculation was performed for different starting phases and the CTV dose coverageV95%and homogeneityD5%-D95%were analysed.Main results.For the geometrical phantoms with rigid motion perpendicular to the beam and parallel to the magnetic field, a comparable dosimetric effect was observed independent of the magnetic field. Also for the five 4DCT(MRI) cases, the influence of motion was comparable for all magnetic field strengths with and without gantry angle correction. On average, the motion-induced decrease in CTVV95%from the static plan was 17.0% and 18.9% for 1.5 T and 0.5 T, respectively, and 19.9% without magnetic field.Significance.For the first time, this study investigates the combined impact of magnetic fields and respiratory motion on MR-guided proton therapy. The comparable dosimetric effects irrespective of magnetic field strength indicate that the effects of motion for future MR-guided proton therapy may not be worse than for conventional PBS proton therapy.

Fano cavity test and investigation of the response of the Roos chamber irradiated by proton beams in perpendicular magnetic fields up to 1 T

Objective. The aim of this work is to investigate the response of the Roos chamber (type 34001) irradiated by clinical proton beams in magnetic fields.Approach. At first, a Fano test was implemented in Monte Carlo software package GATE version 9.2 (based on Geant4 version 11.0.2) using a cylindrical slab geometry in a magnetic field up to 1 T. In accordance to an experimental setup (Fuchset al2021), the magnetic field correction factorskQB⃗of the Roos chamber were determined at different energies up to 252 MeV and magnetic field strengths up to 1 T, by separately simulating the ratios of chamber signalsMQ/MQB⃗,without and with magnetic field, and the dose-conversion factorsDw,QB⃗/Dw,Qin a small cylinder of water, with and without magnetic field. Additionally, detailed simulations were carried out to understand the observed magnetic field dependence.Main results. The Fano test was passed with deviations smaller than 0.25% between 0 and 1 T. The ratios of the chamber signals show both energy and magnetic field dependence. The maximum deviation of the dose-conversion factors from unity of 0.22% was observed at the lowest investigated proton energy of 97.4 MeV andB⃗= 1 T. The resultingkQB⃗factors increase initially with the applied magnetic field and decrease again after reaching a maximum at around 0.5 T; except for the lowest 97.4 MeV beam that show no observable magnetic field dependence. The deviation from unity of the factors is also larger for higher proton energies, where the maximum lies at 1.0035(5), 1.0054(7) and 1.0069(7) for initial energies ofE0= 152, 223.4 and 252 MeV, respectively.Significance. Detailed Monte Carlo studies showed that the observed effect can be mainly attributed to the differences in the transport of electrons produced both outside and inside of the air cavity in the presence of a magnetic field.

Proton dosimetry in a magnetic field: Measurement and calculation of magnetic field correction factors for a plane-parallel ionization chamber

BACKGROUND

The combination of magnetic resonance imaging and proton therapy offers the potential to improve cancer treatment. The magnetic field (MF)-dependent change in the dosage of ionization chambers in magnetic resonance imaging-integrated proton therapy (MRiPT) is considered by the correction factork B ⃗ , M , Q $k_{\vec{B},M,Q}$ , which needs to be determined experimentally or computed via Monte Carlo (MC) simulations.

PURPOSE

In this study,k B ⃗ , M , Q $k_{\vec{B},M,Q}$ was both measured and simulated with high accuracy for a plane-parallel ionization chamber at different clinical relevant proton energies and MF strengths.

MATERIAL AND METHODS

The dose-response of the Advanced Markus chamber (TM34045, PTW, Freiburg, Germany) irradiated with homogeneous 10 × $\times$ 10 cm2 $^2$ quasi mono-energetic fields, using 103.3, 128.4, 153.1, 223.1, and 252.7 MeV proton beams was measured in a water phantom placed in the MF of an electromagnet with MF strengths of 0.32, 0.5, and 1 T. The detector was positioned at a depth of 2 g/cm2 $^2$ in water, with chamber electrodes parallel to the MF lines and perpendicular to the proton beam incidence direction. The measurements were compared with TOPAS MC simulations utilizing COMSOL-calculated 0.32, 0.5, and 1 T MF maps of the electromagnet.k B ⃗ , M , Q $k_{\vec{B},M,Q}$ was calculated for the measurements for all energies and MF strengths based on the equation:k B ⃗ , M , Q = M Q M Q B ⃗ $k_{\vec{B},M,Q}=\frac{M_\mathrm{Q}}{M_\mathrm{Q}^{\vec{B}}}$ , whereM Q B ⃗ $M_\mathrm{Q}^{\vec{B}}$ andM Q $M_\mathrm{Q}$ were the temperature and air-pressure corrected detector readings with and without the MF, respectively. MC-based correction factors were determined ask B ⃗ , M , Q = D det D det B ⃗ $k_{\vec{B},M,Q}=\frac{D_\mathrm{det}}{D_\mathrm{det}^{\vec{B}}}$ , whereD det B ⃗ $D_\mathrm{det}^{\vec{B}}$ andD det $D_\mathrm{det}$ were the doses deposited in the air cavity of the ionization chamber model with and without the MF, respectively. Furthermore, MF effects on the chamber dosimetry are studied using MC simulations, examining the impact on the absorbed dose-to-water (D W $D_{W}$ ) and the shift in depth of the Bragg peak.

RESULTS

The detector showed a reduced dose-response for all measured energies and MF strengths, resulting in experimentally determinedk B ⃗ , M , Q $k_{\vec{B},M,Q}$ values larger than unity. For all energies and MF strengths examined,k B ⃗ , M , Q $k_{\vec{B},M,Q}$ ranged between 1.0065 and 1.0205. The dependence on the energy and the MF strength was found to be non-linear with a maximum at 1 T and 252.7 MeV. The MC simulatedk B ⃗ , M , Q $k_{\vec{B},M,Q}$ values agreed with the experimentally determined correction factors within their standard deviations with a maximum difference of 0.6%. The MC calculated impact onD W $D_{W}$ was smaller 0.2 %.

CONCLUSION

For the first time, measurements and simulations were compared for proton dosimetry within MFs using an Advanced Markus chamber. Good agreement ofk B ⃗ , M , Q $k_{\vec{B},M,Q}$ was found between experimentally determined and MC calculated values. The performed benchmarking of the MC code allows for calculatingk B ⃗ , M , Q $k_{\vec{B},M,Q}$ for various ionization chamber models, MF strengths and proton energies to generate the data needed for a proton dosimetry protocol within MFs and is, therefore, a step towards MRiPT.

A GPU-based fast Monte Carlo code that supports proton transport in magnetic field for radiation therapy

This paper presents the effort to extend a previously reported code ARCHER, a GPU-based Monte Carlo (MC) code for coupled photon and electron transport, into protons including the consideration of magnetic fields. The proton transport is modeled using a Class-II condensed-history algorithm with continuous slowing-down approximation. The model includes ionization, multiple scattering, energy straggling, elastic and inelastic nuclear interactions, as well as deflection due to the Lorentz force in magnetic fields. An additional direction change is added for protons at the end of each step in the presence of the magnetic field. Secondary charge particles, except for protons, are terminated depositing kinetic energies locally, whereas secondary neutral particles are ignored. Each proton is transported step by step until its energy drops to below 0.5 MeV or when the proton leaves the phantom. The code is implemented using the compute unified device architecture (CUDA) platform for optimized GPU thread-level parallelism and efficiency. The code is validated by comparing it against TOPAS. Comparisons of dose distributions between our code and TOPAS for several exposure scenarios, ranging from single square beams in water to patient plan with magnetic fields, show good agreement. The 3D-gamma pass rate with a 2 mm/2% criterion in the region with dose greater than 10% of the maximum dose is computed to be over 99% for all tested cases. Using a single NVIDIA TITAN V GPU card, the computational time of ARCHER is found to range from 0.82 to 4.54 seconds for 1 × 107 proton histories. Compared to a few hours running on TOPAS, this speed improvement is significant. This work presents, for the first time, the performance of a GPU-based MC code to simulate proton transportation magnetic fields, demonstrating the feasibility of accurate and efficient dose calculations in potential magnetic resonance imaging (MRI)-guided proton therapy.

Technical note: Experimental dosimetric characterization of proton pencil beam distortion in a perpendicular magnetic field of an in-beam MR scanner

BACKGROUND

As it promises more precise and conformal radiation treatments, magnetic resonance imaging-integrated proton therapy (MRiPT) is seen as a next step in image guidance for proton therapy. The Lorentz force, which affects the course of the proton pencil beams, presents a problem for beam delivery in the presence of a magnetic field.

PURPOSE

To investigate the influence of the 0.32-T perpendicular magnetic field of an MR scanner on the delivery of proton pencil beams inside an MRiPT prototype system.

METHODS

An MRiPT prototype comprising of a horizontal pencil beam scanning beam line and an open 0.32-T MR scanner was used to evaluate the impact of the vertical magnetic field on proton beam deflection and dose spot pattern deformation. Three different proton energies (100, 150, and 220 MeV) and two spot map sizes (15 × 15 and 30 × 20 cm2 ) at four locations along the beam path without and with magnetic field were measured. Pencil-beam dose spots were measured using EBT3 films and a 2D scintillation detector. To study the magnetic field effects, a 2D Gaussian fit was applied to each individual dose spot to determine the central position( X , Y ) $(X,Y)$ , minimum and maximum lateral standard deviation (σ m i n $\sigma _{min}$ andσ m a x $\sigma _{max}$ ), orientation (θ), and the eccentricity (ε).

RESULTS

The dose spots were subjected to three simultaneous effects: (a) lateral horizontal beam deflection, (b) asymmetric trapezoidal deformation of the dose spot pattern, and (c) deformation and rotation of individual dose spots. The strongest effects were observed at a proton energy of 100 MeV with a horizontal beam deflection of 14-186 mm along the beam path. Within the central imaging field of the MR scanner, the maximum relative dose spot sizeσ m a x $\sigma _{max}$ decreased by up to 3.66%, whileσ m i n $\sigma _{min}$ increased by a maximum of 2.15%. The largest decrease and increase in the eccentricity of the dose spots were 0.08 and 0.02, respectively. The spot orientation θ was rotated by a maximum of 5.39°. At the higher proton energies, the same effects were still seen, although to a lesser degree.

CONCLUSIONS

The effect of an MRiPT prototype's magnetic field on the proton beam path, dose spot pattern, and dose spot form has been measured for the first time. The findings show that the impact of the MF must be appropriately recognized in a future MRiPT treatment planning system. The results emphasize the need for additional research (e.g., effect of magnetic field on proton beams with range shifters and impact of MR imaging sequences) before MRiPT applications can be employed to treat patients.

A fast analytical dose calculation approach for MRI-guided proton therapy

Objective.Magnetic resonance (MR) is an innovative technology for online image guidance in conventional radiotherapy and is also starting to be considered for proton therapy as well. For MR-guided therapy, particularly for online plan adaptations, fast dose calculation is essential. Monte Carlo (MC) simulations, however, which are considered the gold standard for proton dose calculations, are very time-consuming. To address the need for an efficient dose calculation approach for MRI-guided proton therapy, we have developed a fast GPU-based modification of an analytical dose calculation algorithm incorporating beam deflections caused by magnetic fields.Approach.Proton beams (70-229 MeV) in orthogonal magnetic fields (0.5/1.5 T) were simulated using TOPAS-MC and central beam trajectories were extracted to generate look-up tables (LUTs) of incremental rotation angles as a function of water-equivalent depth. Beam trajectories are then reconstructed using these LUTs for the modified ray casting dose calculation. The algorithm was validated against MC in water, different materials and for four example patient cases, whereby it has also been fully incorporated into a treatment plan optimisation regime.Main results.Excellent agreement between analytical and MC dose distributions could be observed with sub-millimetre range deviations and differences in lateral shifts <2 mm even for high densities (1000 HU). 2%/2 mm gamma pass rates were comparable to the 0 T scenario and above 94.5% apart for the lung case. Further, comparable treatment plan quality could be achieved regardless of magnetic field strength.Significance.A new method for accurate and fast proton dose calculation in magnetic fields has been developed and successfully implemented for treatment plan optimisation.

The dose accumulation and the impact of deformable image registration on dose reporting parameters in a moving patient undergoing proton radiotherapy

INTRODUCTION

Potential changes in patient anatomy during proton radiotherapy may lead to a deviation of the delivered dose. A dose estimate can be computed through a deformable image registration (DIR) driven dose accumulation. The present study evaluates the accumulated dose uncertainties in a patient subject to an inadvertent breathing associated motion.

MATERIALS AND METHODS

A virtual lung tumour was inserted into a pair of single participant landmark annotated computed tomography images depicting opposite breathing phases, with the deep inspiration breath-hold the planning reference and the exhale the off-reference geometry. A novel Monte Carlo N-Particle, Version 6 (MCNP6) dose engine was developed, validated and used in treatment plan optimization. Three DIR methods were compared and used to transfer the exhale simulated dose to the reference geometry. Dose conformity and homogeneity measures from International Committee on Radioactivity Units and Measurements (ICRU) reports 78 and 83 were evaluated on simulated dose distributions registered with different DIR algorithms.

RESULTS

The MCNP6 dose engine handled patient-like geometries in reasonable dose calculation times. All registration methods were able to align image associated landmarks to distances, comparable to voxel sizes. A moderate deterioration of ICRU measures was encountered in comparing doses in on and off-reference anatomy. There were statistically significant DIR driven differences in ICRU measures, particularly a 10% difference in the relative D_98% for planning tumour volume and in the 3 mm/3% gamma passing rate.

CONCLUSIONS

T he dose accumulation over two anatomies resulted in a DIR driven uncertainty, important in reporting the associated ICRU measures for quality assurance.

A portable magnet for radiation biology and dosimetry studies in magnetic fields

BACKGROUND AND PURPOSE

In the current and rapidly evolving era of real-time MRI-guided radiotherapy, our radiation biology and dosimetry knowledge is being tested in a novel way. This paper presents the successful design and implementation of a portable device used to generate strong localized magnetic fields. These are ideally suited for small scale experiments that mimic the magnetic field environment inside an MRI-linac system, or more broadly MRI-guided particle therapy as well.

MATERIALS AND METHODS

A portable permanent magnet based device employing an adjustable steel yoke and magnetic field focusing cones has been designed, constructed and tested. The apparatus utilises two banks of Nd₂ Fe₁₄ B permanent magnets totalling around 50 kg in mass to generate a strong magnetic field throughout a small volume between two pole tips. The yoke design allows adjustment of the pole tip gap and exchanging of the focusing cones. Further to this, beam portal holes are present in the yoke and focusing cones, allowing for radiation beams of up to 5 x 5 cm² to pass through the region of high magnetic field between the focusing cone tips. Finite element magnetic modelling was performed to design and characterise the performance of the device. Automated physical measurements of the magnetic field components at various locations were measured to confirm the performance. The adjustable pole gap and interchangeable cones allows rapid changing of the experimental set-up to allow different styles of measurements to be performed.

RESULTS

A mostly uniform magnetic field of 1.2 T can be achieved over a volume of at least 3 x 3 x 3 cm³ . This can be reduced in strength to 0.3 T but increased in volume to 10 x 10 x 10 cm³ via removal of the cone tips and/or adjustment of the steel yoke. Although small, these volumes are sufficient to house radiation detectors, cell culture dishes and various phantom arrangements targeted at examining small radiation field dosimetry inside magnetic field strengths that can be changed with ease. Most important is the ability to align the magnetic field both perpendicular to, or inline with the radiation beam. To date, the system has been successfully used to conduct published research in the areas of radiation detector performance, lung phantom dosimetry, and how small clinical electron beams behave in these strong magnetic fields.

CONCLUSIONS

A portable, relatively inexpensive, and simple to operate device has successfully been constructed and used for performing radiation oncology studies around the theme of MRI-guided radiotherapy. This can be in either inline and perpendicular magnetic fields of up to 1.2 T with x-ray and particle beams.

Converging Proton Minibeams with Magnetic Fields for Optimized Radiation Therapy: A Proof of Concept

Proton MiniBeam Radiation Therapy (pMBRT) is a novel strategy that combines the benefits of minibeam radiation therapy with the more precise ballistics of protons to further optimize the dose distribution and reduce radiation side effects. The aim of this study is to investigate possible strategies to couple pMBRT with dipole magnetic fields to generate a converging minibeam pattern and increase the center-to-center distance between minibeams. Magnetic field optimization was performed so as to obtain the same transverse dose profile at the Bragg peak position as in a reference configuration with no magnetic field. Monte Carlo simulations reproducing realistic pencil beam scanning settings were used to compute the dose in a water phantom. We analyzed different minibeam generation techniques, such as the use of a static multislit collimator or a dynamic aperture, and different magnetic field positions, i.e., before or within the water phantom. The best results were obtained using a dynamic aperture coupled with a magnetic field within the water phantom. For a center-to-center distance increase from 4 mm to 6 mm, we obtained an increase of peak-to-valley dose ratio and decrease of valley dose above 50%. The results indicate that magnetic fields can be effectively used to improve the spatial modulation at shallow depth for enhanced healthy tissue sparing.

Integrated MRI-guided proton therapy planning: accounting for the full MRI field in a perpendicular system

PURPOSE

To present a first study on the treatment planning feasibility in perpendicular field MRI-integrated proton therapy which considers the full transport of protons from the pencil beam scanning assembly to the patient inside the MRI scanner.

METHODS

A generic proton pencil beam scanning (PBS) gantry was modelled as being integrated with a realistic split-bore MRI system in the perpendicular orientation. MRI field strengths were modeled as 0.5 T, 1 T, and 1.5 T. The PBS beam delivery and dose calculation was modeled using the TOPAS Monte Carlo toolkit coupled with matRad as the optimizer engine. A water phantom, liver and prostate plans were evaluated and optimized in the presence of the full MRI field distribution. A simple combination of gantry angle offset and small PBS nozzle skew was used to direct the proton beams along a path that closely follows the reference planning scenario, i.e. without magnetic field.

RESULTS

All planning metrics could be successfully achieved with the inclusion of gantry angle offsets in the range of 8°-29° when coupled with a PBS nozzle skew of 1.6°-4.4°. These two hardware based corrections were selected to minimize the average Euclidean distance (AED) in the beam path enabling the proton beams to travel inside the patient in a path that is close to the original path (AED smaller than 3 mm at 1.5 T). Final dose optimization, performed through further changes in the pencil beam scanning delivery, was then shown to be feasible for our selection of plans studied yielding comparable plan quality metrics to reference conditions.

CONCLUSIONS

For the first time, we have shown a robust method to account for the full proton beam deflection in a perpendicular orientation MRI-integrated proton therapy. These results support the ongoing development of the current prototype systems. This article is protected by copyright. All rights reserved.

Future Developments in Charged Particle Therapy: Improving Beam Delivery for Efficiency and Efficacy

The physical and clinical benefits of charged particle therapy (CPT) are well recognized. However, the availability of CPT and complete exploitation of dosimetric advantages are still limited by high facility costs and technological challenges. There are extensive ongoing efforts to improve upon these, which will lead to greater accessibility, superior delivery, and therefore better treatment outcomes. Yet, the issue of cost remains a primary hurdle as utility of CPT is largely driven by the affordability, complexity and performance of current technology. Modern delivery techniques are necessary but limited by extended treatment times. Several of these aspects can be addressed by developments in the beam delivery system (BDS) which determines the overall shaping and timing capabilities enabling high quality treatments. The energy layer switching time (ELST) is a limiting constraint of the BDS and a determinant of the beam delivery time (BDT), along with the accelerator and other factors. This review evaluates the delivery process in detail, presenting the limitations and developments for the BDS and related accelerator technology, toward decreasing the BDT. As extended BDT impacts motion and has dosimetric implications for treatment, we discuss avenues to minimize the ELST and overview the clinical benefits and feasibility of a large energy acceptance BDS. These developments support the possibility of advanced modalities and faster delivery for a greater range of treatment indications which could also further reduce costs. Further work to realize methodologies such as volumetric rescanning, FLASH, arc, multi-ion and online image guided therapies are discussed. In this review we examine how increased treatment efficiency and efficacy could be achieved with improvements in beam delivery and how this could lead to faster and higher quality treatments for the future of CPT.

Adaptive proton therapy

Radiation therapy treatments are typically planned based on a single image set, assuming that the patient's anatomy and its position relative to the delivery system remains constant during the course of treatment. Similarly, the prescription dose assumes constant biological dose-response over the treatment course. However, variations can and do occur on multiple time scales. For treatment sites with significant intra-fractional motion, geometric changes happen over seconds or minutes, while biological considerations change over days or weeks. At an intermediate timescale, geometric changes occur between daily treatment fractions. Adaptive radiation therapy is applied to consider changes in patient anatomy during the course of fractionated treatment delivery. While traditionally adaptation has been done off-line with replanning based on new CT images, online treatment adaptation based on on-board imaging has gained momentum in recent years due to advanced imaging techniques combined with treatment delivery systems. Adaptation is particularly important in proton therapy where small changes in patient anatomy can lead to significant dose perturbations due to the dose conformality and finite range of proton beams. This review summarizes the current state-of-the-art of on-line adaptive proton therapy and identifies areas requiring further research.

Toward MR-integrated proton therapy: modeling the potential benefits for liver tumors

Magnetic resonance imaging (MRI)-integrated proton therapy (MRiPT) is envisioned to improve treatment quality for many cancer patients. However, given the availability of alternative image-guided strategies, its clinical need is yet to be justified. This study aims to compare the expected clinical outcomes of MRiPT with standard of practice cone-beam CT (CBCT)-guided PT, and other MR-guided methods, i.e. offline MR-guided PT and MR-linac, for treatment of liver tumors. Clinical outcomes were assessed by quantifying the dosimetric and biological impact of target margin reduction enabled by each image-guided approach. Planning target volume (PTV) margins were calculated using random and systematic setup, delineation and motion uncertainties, which were quantified by analyzing longitudinal MRI data for 10 patients with liver tumors. Proton treatment plans were created using appropriate PTV margins for each image-guided PT method. Photon plans with margins equivalent to MRiPT were generated to represent MR-linac. Normal tissue complication probabilities (NTCP) of the uninvolved liver were compared. We found that PTV margin can be reduced by 20% and 40% for offline MR-guided PT and MRiPT, respectively, compared with CBCT-guided PT. Furthermore, clinical target volume expansion could be largely alleviated when delineating on MRI rather than CT. Dosimetric implications included decreased equivalent mean dose of the uninvolved liver, i.e. up to 24.4 Gy and 27.3 Gy for offline MR-guided PT and MRiPT compared to CBCT-guided PT, respectively. Considering Child-Pugh score increase as endpoint, NTCP of the uninvolved liver was significantly decreased for MRiPT compared to CBCT-guided PT (up to 48.4%,p < 0.01), offline MR-guided PT (up to 12.9%,p < 0.01) and MR-linac (up to 30.8%,p < 0.05). Target underdose was possible in the absence of MRI-guidance (D90 reduction up to 4.2 Gy in 20% of cases). In conclusion, MRiPT has the potential to significantly reduce healthy liver toxicities in patients with liver tumors. It is superior to other image-guided techniques currently available.

Dosimetric Deviations of Bragg-Peak Position Shifts in Uniform Magnetic Fields for Magnetic Resonance Imaging-Guiding Proton Radiotherapy: A Monte Carlo Study

Objective: To investigate dosimetric deviations in scanning protons for Bragg-peak position shifts, which were caused by proton spiral tracks in an ideal uniform field of magnetic resonance (MRI) imaging-guided proton radiotherapy (MRI-IGPRT).

Methods: The FLUKA Monte-Carlo (MC) code was used to simulate the spiral tracks of protons penetrating water with initial energies of 70–270 MeV under the influence of field strength of 0.0–3.0 Tesla in commercial MRI systems. Two indexes, lateral shift (marked as WD) perpendicular to the field and a penetration-depth shift (marked as ΔDD) along the beam path, were employed for the Bragg-peak position of spiral proton track analysis. A comparison was performed between MC and classical analytical model to check the simulation results. The shape of the 2D/3D dose distribution of proton spots at the depth of Bragg-Peak was also investigated. The ratio of Gaussian-fit value between longitudinal and transverse major axes was used to indicate the asymmetric index. The skewness of asymmetry was evaluated at various dose levels by the radius ratio of circumscribed and inscribed circles by fitting a semi-ellipse circle of 2D distribution.

Results: The maximum of WD deflection is 2.82 cm while the maximum of shortening ΔDD is 0.44 cm for proton at 270 MeV/u under a magnetic field of 3.0 Tesla. The trend of WD and ΔDD from MC simulation was consistent with the analytical model, which means the reverse equation of the analytical model can be applied to determine the proper field strength of the magnet and the initial energy of the proton for the planned dose. The asymmetry of 2D/3D dose distribution under the influence of a magnetic field was increased with higher energy, and the skewness of asymmetry for one proton energy at various dose levels was also increased with a larger radius, i.e., a lower dose level.

Conclusions: The trend of the spiral proton track under a uniform magnetic field was obtained in this study using either MC simulation or the analytical model, which can provide an optimized and planned dose of the proton beam in the clinical application of MRI-IGPRT.

Intra-fractional per-beam adaptive workflow to mitigate the need for a rotating gantry during MRI-guided proton therapy

The integration of real-time magnetic resonance imaging (MRI)-guidance and proton therapy would potentially improve the proton dose steering capability by reducing daily uncertainties due to anatomical variations. The use of a fixed beamline coupled with an axial patient couch rotation would greatly simplify the proton delivery with MRI-guidance. Nonetheless, it is mandatory to assure that the plan quality is not deteriorated by the anatomical deformations due to patient rotation. In this work, an in-house tool allowing for intra-fractional per-beam adaptation of intensity-modulated proton plans (BeamAdapt) was implemented through features available in RayStation. A set of three MRIs was acquired for two healthy volunteers (V1, V2): (1) no rotation/static, (2) rotation to the right and (3) left. V1 was rotated by 15º, to simulate a clinical pediatric abdominal case and V2 by 45º, to simulate an extreme patient rotation case. For each volunteer, a total of four intensity-modulated pencil beam scanning plans were optimized on the static MRI using virtual abdominal targets and 2-3 posterior-oblique beams. Beam angles were defined according to the angulations on the rotated MRIs. With BeamAdapt, each original plan was first converted into separate plans with one beam per plan. In an iterative order, individual beam doses were non-rigidly deformed to the rotated anatomies and re-optimized accounting for the consequent deformations and the beam doses delivered so far. For evaluation, the final adapted dose distribution was propagated back to the static MRI. Planned and adapted dose distributions were compared by computing relative differences between dose-volume histogram (DVH) metrics. Absolute target dose differences were on average below 1% and mean dose organs-at-risk differences were below 3%. With BeamAdapt, not only intra-fractional per-beam proton plan adaptation coupled with axial patient rotation is possible but also the need for a rotating gantry during MRI-guidance might be mitigated.

Anatomic changes in head and neck intensity-modulated proton therapy: Comparison between robust optimization and online adaptation

BACKGROUND/PURPOSE

Setup variations and anatomical changes can severely affect the quality of head and neck intensity-modulated proton therapy (IMPT) treatments. The impact of these changes can be alleviated by increasing the plan's robustness a priori, or by adapting the plan online. This work compares these approaches in the context of head and neck IMPT.

MATERIALS/METHODS

A representative cohort of 10 head and neck squamous cell carcinoma (HNSCC) patients with daily cone-beam computed tomography (CBCT) was evaluated. For each patient, three IMPT plans were created: 1- a classical robust optimization (cRO) plan optimized on the planning CT, 2- an anatomical robust optimization (aRO) plan additionally including the two first daily CBCTs and 3- a plan optimized without robustness constraints, but online-adapted (OA) daily, using a constrained spot intensity re-optimization technique only.

RESULTS

The cumulative dose following OA fulfilled the clinical objective of both the high-risk and low-risk clinical target volumes (CTV) coverage in all 10 patients, compared to 8 for aRO and 4 for cRO. aRO did not significantly increase the dose to most organs at risk compared to cRO, although the integral dose was higher. OA significantly reduced the integral dose to healthy tissues compared to both robust methods, while providing equivalent or superior target coverage.

CONCLUSION

Using a simple spot intensity re-optimization, daily OA can achieve superior target coverage and lower dose to organs at risk than robust optimization methods.

Characterization of magnetic interference and image artefacts during simultaneous in-beam MR imaging and proton pencil beam scanning

For the first time, a low-field open magnetic resonance (MR) scanner was combined with a proton pencil beam scanning (PBS) research beamline. The aim of this study was to characterize the magnetic fringe fields produced by the PBS system and measure their effects on MR image quality during simultaneous PBS irradiation and image acquisition. A magnetic field camera measured the change in central resonance frequency (Δf _res) and magnetic field homogeneity (ΔMFH) of the B₀ field of the MR scanner during operation of the beam transport and scanning magnets. The beam energy was varied between 70 - 220 MeV and beam scanning was performed along the central horizontal and vertical axis of a 48 × 24 cm² radiation field. The time structure of the scanning magnets' fringe fields was simultaneously recorded by a tri-axial Hall probe. MR imaging experiments were conducted using the ACR (American College of Radiology) Small MRI Phantom and a spoiled gradient echo pulse sequence during simultaneous volumetric irradiation. Computer simulations were performed to predict the effects of B ₀ field perturbations due to PBS irradiation on MR image formation in k-space. Setting the beam transport magnets, horizontal and vertical scanning magnets resulted in a maximum Δf _res of 50, 235 and 4 Hz, respectively. The ΔMFH was less than 3 parts per million for all measurements. MR images acquired during beam energy variation and vertical beam scanning showed no visual loss in image quality. However, MR images acquired during horizontal beam scanning showed severe coherent ghosting artefacts in phase encoding direction. Both simulated and measured k-space phase maps prove that these artefacts are caused by phase-offsets. This study shows first experimental evidence that simultaneous in-beam MR imaging during proton PBS irradiation is subject to severe loss of image quality in the absence of magnetic decoupling between the PBS and MR system.

Evaluation of an a priori scatter correction algorithm for cone-beam computed tomography based range and dose calculations in proton therapy

BACKGROUND AND PURPOSE

Scatter correction of cone-beam computed tomography (CBCT) projections may enable accurate online dose-delivery estimations in photon and proton-based radiotherapy. This study aimed to evaluate the impact of scatter correction in CBCT-based proton range/dose calculations, in scans acquired in both proton and photon gantries.

MATERIAL AND METHODS

CBCT projections of a Catphan and an Alderson phantom were acquired on both a proton and a photon gantry. The scatter corrected CBCTs (corrCBCTs) and the clinical reconstructions (stdCBCTs) were compared against CTs rigidly registered to the CBCTs (rigidCTs). The CBCTs of the Catphan phantom were segmented by materials for CT number analysis. Water equivalent path length (WEPL) maps were calculated through the Alderson phantom while proton plans optimized on the rigidCT and recalculated on all CBCTs were compared in a gamma analysis.

RESULTS

In medium and high-density materials, the corrCBCT CT numbers were much closer to those of the rigidCT than the stdCBCTs. E.g. in the 50% bone segmentations the differences were reduced from above 300 HU (with stdCBCT) to around 60-70 HU (with corrCBCT). Differences in WEPL from the rigidCT were typically well below 5 mm for the corrCBCTs, compared to well above 10 mm for the stdCBCTs with the largest deviations in the head and thorax regions. Gamma pass rates (2%/2mm) when comparing CBCT-based dose re-calculations to rigidCT calculations were improved from around 80% (with stdCBCT) to mostly above 90% (with corrCBCT).

CONCLUSION

Scatter correction leads to substantial artefact reductions, improving accuracy of CBCT-based proton range/dose calculations.

Exploiting the full potential of proton therapy: An update on the specifics and innovations towards spatial or temporal optimisation of dose delivery

Prescription and delivery of protons are somewhat different compared to photons and may influence outcomes (tumour control and toxicity). These differences should be taken into account to fully exploit the clinical potential of proton therapy. Innovations in proton therapy treatment are also required to widen the therapeutic window and determine appropriate populations of patients that would benefit from new treatments. Therefore, strategies are now being developed to reduce side effects to critical normal tissues using alternative treatment configurations and new spatial or temporal-driven optimisation approaches. Indeed, spatiotemporal optimisation (based on flash, proton minibeam radiation therapy or hypofractionated delivery methods) has been gaining some attention in proton therapy as a mean of improving (biological and physical) dose distribution. In this short review, the main differences in planning and delivery between protons and photons, as well as some of the latest developments and methodological issues (in silico modelling) related to providing scientific evidence for these new techniques will be discussed.

MR-guided proton therapy: a review and a preview

Background

The targeting accuracy of proton therapy (PT) for moving soft-tissue tumours is expected to greatly improve by real-time magnetic resonance imaging (MRI) guidance. The integration of MRI and PT at the treatment isocenter would offer the opportunity of combining the unparalleled soft-tissue contrast and real-time imaging capabilities of MRI with the most conformal dose distribution and best dose steering capability provided by modern PT. However, hybrid systems for MR-integrated PT (MRiPT) have not been realized so far due to a number of hitherto open technological challenges. In recent years, various research groups have started addressing these challenges and exploring the technical feasibility and clinical potential of MRiPT. The aim of this contribution is to review the different aspects of MRiPT, to report on the status quo and to identify important future research topics.

Methods

Four aspects currently under study and their future directions are discussed: modelling and experimental investigations of electromagnetic interactions between the MRI and PT systems, integration of MRiPT workflows in clinical facilities, proton dose calculation algorithms in magnetic fields, and MRI-only based proton treatment planning approaches.

Conclusions

Although MRiPT is still in its infancy, significant progress on all four aspects has been made, showing promising results that justify further efforts for research and development to be undertaken. First non-clinical research solutions have recently been realized and are being thoroughly characterized. The prospect that first prototype MRiPT systems for clinical use will likely exist within the next 5 to 10 years seems realistic, but requires significant work to be performed by collaborative efforts of research groups and industrial partners.

The effects of a transverse magnetic field on the dose enhancement of nanoparticles in a proton beam: a Monte Carlo simulation

High-Z nanoparticles (NP) as radio-sensitization agents provide the feasibility of dose localization within the tumor in radiotherapy. Dose enhancement of NPs in the presence of a magnetic field (MF) could be challenged when magnetic resonance imaging (MRI) systems are used as an image-guided system. The MF can influence dose enhancement of NPs at their interfaces and surrounding medium and affect their dose deposition behavior. In the TOPAS Monte Carlo code, gold nanoparticle (GNP) and superparamagnetic iron oxide nanoparticle (SPION) were irradiated using 70 and 150 MeV proton beams, in presence of transverse MF strengths with 0, 1, 3, and 7 T. The changes in the liberated secondary electrons from NPs and their dose enhancement ratio (DER), magnetic dose enhancement ratio (MDER), and angular dose distribution in 10 nm shell thicknesses up to 500 nanometers from their centers were measured. The central plane of NPs was considered as a scorer. Its thickness was 2 nm and divided into 6-degree sectors with 10 nm radial length. The dose deposition in this voxelated scorer was calculated. The values of the deposited doses around NPs decrease rapidly while the DERs resulted from the secondary electrons are increased. MDERs are changed within [Formula: see text] and [Formula: see text] for 20 and 50 nm radius NPs, respectively. The variation in the angular dose distribution around a singular NP was not considerable when different MF strengths were applied. The dose values in the voxelated central plane show very similar results for the same NPs types in the different MF strengths. The typically used MF in the MRI systems would not considerably affect the energy deposition behavior of the secondary electrons produced in the interaction of proton beam with NPs, at least in the near vicinity of NPs. The DERs of NPs in a water medium resulted from emerged secondary electrons, experience a low degree of perturbation in the presence of an MF. The results of this study show that the NPs as dose enhancement agents can also be used in an MF without pronounced modification in their efficacy.

Online daily adaptive proton therapy

It is recognized that the use of a single plan calculated on an image acquired some time before the treatment is generally insufficient to accurately represent the daily dose to the target and to the organs at risk. This is particularly true for protons, due to the physical finite range. Although this characteristic enables the generation of steep dose gradients, which is essential for highly conformal radiotherapy, it also tightens the dependency of the delivered dose to the range accuracy. In particular, the use of an outdated patient anatomy is one of the most significant sources of range inaccuracy, thus affecting the quality of the planned dose distribution. A plan should be ideally adapted as soon as anatomical variations occur, ideally online. In this review, we describe in detail the different steps of the adaptive workflow and discuss the challenges and corresponding state-of-the art developments in particular for an online adaptive strategy.

Proton beam radiotherapy for pancreas cancer

Pancreatic carcinoma is a challenging malignancy to manage with a very poor prognosis. Despite continued difficulties in its management, there have been incremental improvements in outcomes over the past several decades. Achieving the best oncologic outcomes requires a multimodality approach including surgery, chemotherapy, and radiotherapy. Proton radiotherapy enables the delivery of high-dose radiotherapy to the tumor or resection bed while sparing nearby critical organs. Due to their unique physical properties, protons can deliver radiotherapy dose distributions that are not achievable with photons (X-rays) even with advanced photon delivery techniques (e.g., intensity-modulated radiotherapy). Improved dose distributions can lead to reduced treatment toxicity and enable treatment intensification. As better chemotherapy regimens lead to better systemic disease control, it will become increasingly important that local-regional control is achieved. This will in part be accomplished by combining better radiotherapy with more active chemotherapies. Proton radiotherapy provides an excellent means for achieving this.

Benchmarking a GATE/Geant4 Monte Carlo model for proton beams in magnetic fields

Purpose

Magnetic resonance guidance in proton therapy (MRPT) is expected to improve its current performance. The combination of magnetic fields with clinical proton beam lines poses several challenges for dosimetry, treatment planning and dose delivery. Proton beams are deflected by magnetic fields causing considerable changes in beam trajectories and also a retraction of the Bragg peak positions. A proper prediction and compensation of these effects is essential to ensure accurate dose calculations. This work aims to develop and benchmark a Monte Carlo (MC) beam model for dose calculation of MRPT for static magnetic fields up to 1 T.

Methods

Proton beam interactions with magnetic fields were simulated using the GATE/Geant4 toolkit. The transport of charged particle in custom 3D magnetic field maps was implemented for the first time in GATE. Validation experiments were done using a horizontal proton pencil beam scanning system with energies between 62.4 and 252.7 MeV and a large gap dipole magnet (B = 0–1 T), positioned at the isocenter and creating magnetic fields transverse to the beam direction. Dose was measured with Gafchromic EBT3 films within a homogeneous PMMA phantom without and with bone and tissue equivalent material slab inserts. Linear energy transfer (LET) quenching of EBT3 films was corrected using a linear model on dose‐averaged LET method to ensure a realistic dosimetric comparison between simulations and experiments. Planar dose distributions were measured with the films in two different configurations: parallel and transverse to the beam direction using single energy fields and spread‐out Bragg peaks. The MC model was benchmarked against lateral deflections and spot sizes in air of single beams measured with a Lynx PT detector, as well as dose distributions using EBT3 films. Experimental and calculated dose distributions were compared to test the accuracy of the model.

Results

Measured proton beam deflections in air at distances of 465, 665, and 1155 mm behind the isocenter after passing the magnetic field region agreed with MC‐predicted values within 4 mm. Differences between calculated and measured beam full width at half maximum (FWHM) were lower than 2 mm. For the homogeneous phantom, measured and simulated in‐depth dose profiles showed range and average dose differences below 0.2 mm and 1.2%, respectively. Simulated central beam positions and widths differed <1 mm to the measurements with films. For both heterogenous phantoms, differences within 1 mm between measured and simulated central beam positions and widths were obtained, confirming a good agreement of the MC model.

Conclusions

A GATE/Geant4 beam model for protons interacting with magnetic fields up to 1 T was developed and benchmarked to experimental data. For the first time, the GATE/Geant4 model was successfully validated not only for single energy beams, but for SOBP, in homogeneous and heterogeneous phantoms. EBT3 film dosimetry demonstrated to be a powerful dosimetric tool, once the film response function is LET corrected, for measurements in‐line and transverse to the beam direction in magnetic fields. The proposed MC beam model is foreseen to support treatment planning and quality assurance (QA) activities toward MRPT.

Carbon ion and proton beam irradiation of a normal human TK6 lymphoblastoid cell line within a magnetic field of 1.0 tesla

Background

Considering the increasing simultaneous application of magnetic resonance imaging (MRI) for more precise photon radiotherapy, it will be likely for particle radiotherapy to adopt MRI for future image guiding. It will then be imperative to evaluate the potential biological effects of a magnetic field (MF) on particle irradiation. This study explores such effects on the highly radiosensitive TK6 lymphoblastoid human cell line.

Methods

The following three parameters were measured after irradiation with either carbon ion or proton beams using spread out Bragg peaks and applying different doses within a perpendicular 1.0 T MF: (1) cell survival fraction (14 days postirradiation), (2) treatment-specific apoptosis, which was determined through the measurement of population in the sub-G1 phase, and (3) cell cycle progression by means of flow cytometry. These were compared to the same parameters measured without an MF.

Results

The clonogenic assay in both treatment groups showed almost identical survival curves with overlapping error bars. The calculated α values with and without an MF were 2.18 (σ=0.245) and 2.17 (σ=0.234) for carbon ions and 1.08 (σ=0.138) and 1.13 (σ=0.0679) for protons, respectively. Similarly, the treatment-specific apoptosis and cell cycle progression showed almost identical curves with overlapping error bars. A two-sample, unpooled t-test analysis was implemented for comparison of all mean values and showed p-values >0.05.

Conclusion

No statistically significant difference in biological response of the TK6 cells was observed when they were irradiated using spreadout Bragg peaks within a perpendicular 1.0 T MF as compared to those, which received the same dose without the MF. This should serve as another supporting piece of evidence toward the implementation of MRI in particle radiotherapy, though further research is necessary.

MRI-guided proton therapy planning: accounting for an inline MRI fringe field

MRI-guided proton therapy is being pursued for its promise to provide a more conformal, accurate proton therapy. However, the presence of the magnetic field imposes a challenge for the beam delivery as protons are deflected due to the Lorenz force. In this study, the impact of realistic inline MRI fringe field on IMPT plan delivery is investigated for a water phantom, liver tumor and prostate cancer differing in target volume, shape, and field configuration using Monte Carlo simulations. A method to correct for the shift of the beam spot positions in the presence of the inline magnetic field is presented. Results show that when not accounting for the effect of the magnetic field on the pencil beam delivery, the spot positions are substantially shifted and the quality of delivered plans is significantly deteriorated leading to dose inhomogeneities and creation of hot and cold spots. However, by correcting the pencil beam delivery, the dose quality of the IMPT plans is restored to a high degree. Nevertheless, adaptation of beam delivery alone is not robust regarding different treatment sites. By fully accounting during plan optimization for the dose distortions caused by the fringe and imaging fields, highly conformal IMPT plans are achieved. These results demonstrate proton pencil beam scanning and treatment planning can be adapted for precise delivery of state-of-the-art IMPT plans in MR-guided proton therapy in the presence of an inline MRI fringe field.

Effect of External Magnetic Fields on Biological Effectiveness of Proton Beams

PURPOSE

The purpose is to verify experimentally whether application of magnetic fields longitudinal and perpendicular to a proton beam alters the biological effectiveness of the radiation.

METHODS AND MATERIALS

Proton beams with linear energy transfer of 1.1 and 3.3 keV/μm irradiated human cancer and normal cells under a longitudinal (perpendicular) magnetic field of B_L (B_P) = 0, 0.3, or 0.6 T. Cell survival curves were constructed to evaluate the effects of the magnetic fields on the biological effectiveness. The ratio of dose that would result in a survival fraction of 10% without the magnetic field D_wo to the dose with the magnetic field D_w, R₁₀ = D_wo/D_w, was determined for each cell line and magnetic field.

RESULTS

For cancer cells exposed to the 1.1- (3.3-) keV/μm proton beams, R₁₀s were increased to 1.10 ± 0.07 (1.11 ± 0.07) and 1.11 ± 0.07 (1.12 ± 0.07) by the longitudinal magnetic fields of B_L = 0.3 and 0.6 T, respectively. For normal cells, R₁₀s were increased to 1.13 ± 0.06 (1.17 ± 0.06) and 1.17 ± 0.06 (1.30 ± 0.06) by the B_Ls. In contrast, R₁₀s were not changed significantly from 1 by the perpendicular magnetic fields of B_P = 0.3 and 0.6 T for both cancer and normal cells exposed to 1.1- and 3.3-keV/μm proton beams.

CONCLUSIONS

The biological effectiveness of proton beams was significantly enhanced by longitudinal magnetic fields of B_L = 0.3 and 0.6 T, whereas the biological effectiveness was not altered by perpendicular magnetic fields of the same strengths. This enhancement effect should be taken into account in magnetic resonance imaging guided proton therapy with a longitudinal magnetic field.

Evaluation of proton and photon dose distributions recalculated on 2D and 3D Unet-generated pseudoCTs from T1-weighted MR head scans

Introduction: The recent developments of magnetic resonance (MR) based adaptive strategies for photon and, potentially for proton therapy, require a fast and reliable conversion of MR images to X-ray computed tomography (CT) values. CT values are needed for photon and proton dose calculation. The improvement of conversion results employing a 3D deep learning approach is evaluated. Material and methods: A database of 89 T1-weighted MR head scans with about 100 slices each, including rigidly registered CTs, was created. Twenty-eight validation patients were randomly sampled, and four patients were selected for application. The remaining patients were used to train a 2D and a 3D U-shaped convolutional neural network (Unet). A stack size of 32 slices was used for 3D training. For all application cases, volumetric modulated arc therapy photon and single-field uniform dose pencil-beam scanning proton plans at four different gantry angles were optimized for a generic target on the CT and recalculated on 2D and 3D Unet-based pseudoCTs. Mean (absolute) error (MAE/ME) and a gradient sharpness estimate were used to quantify the image quality. Three-dimensional gamma and dose difference analyses were performed for photon (gamma criteria: 1%, 1 mm) and proton dose distributions (gamma criteria: 2%, 2 mm). Range (80% fall off) differences for beam's eye view profiles were evaluated for protons. Results: Training 36 h for 1000 epochs in 3D (6 h for 200 epochs in 2D) yielded a maximum MAE of 147 HU (135 HU) for the application patients. Except for one patient gamma pass rates for photon and proton dose distributions were above 96% for both Unets. Slice discontinuities were reduced for 3D training at the cost of sharpness. Conclusions: Image analysis revealed a slight advantage of 2D Unets compared to 3D Unets. Similar dose calculation performance was reached for the 2D and 3D network.

Daily adaptive proton therapy - the key to innovative planning approaches for paranasal cancer treatments

Background: For proton therapy of paranasal tumors, field directions avoiding volumes that might change during therapy are typically used. If the plan is optimized on the daily anatomy using daily adapted proton therapy (DAPT) however, field directions crossing the nasal cavities might be feasible. In this study, we investigated the effectiveness of DAPT for enabling narrow-field treatment approaches. Material and methods: For five paranasal tumor patients, representing a wide patient spectrum, anatomically robust 4-field-star and narrow-field plans were calculated and their robustness to anatomical and setup uncertainties was compared with and without DAPT. Based on the nominal planning CTs, per patient up to 125 simulated CTs (simCTs) with different nasal cavity fillings were created and random translations and rotations due to patient setup uncertainties were further simulated. Plans were recalculated or re-optimized on all error scenarios, representing non-adapted and DAPT fractions, respectively. From these, 100 possible treatments (60 GyRBE, 30 fx) were simulated and changes in integral dose, target and organs at risk (OARs) doses evaluated. Results: In comparison to the 4-field-star approach, the use of narrow-fields reduced integral dose between 29% and 56%. If OARs did not overlap with the target, OAR doses were also reduced. Finally, the significantly reduced target coverage in non-adapted treatments (mean V95 reductions of up to 34%) could be almost fully restored with DAPT in all cases (differences <1%). Conclusions: DAPT was found to be not only an effective way to increase plan robustness to anatomical and positional uncertainties, but also opened the possibility to use improved and more conformal field arrangements.

Real-time intrafraction motion monitoring in external beam radiotherapy

Radiotherapy (RT) aims to deliver a spatially conformal dose of radiation to tumours while maximizing the dose sparing to healthy tissues. However, the internal patient anatomy is constantly moving due to respiratory, cardiac, gastrointestinal and urinary activity. The long term goal of the RT community to 'see what we treat, as we treat' and to act on this information instantaneously has resulted in rapid technological innovation. Specialized treatment machines, such as robotic or gimbal-steered linear accelerators (linac) with in-room imaging suites, have been developed specifically for real-time treatment adaptation. Additional equipment, such as stereoscopic kilovoltage (kV) imaging, ultrasound transducers and electromagnetic transponders, has been developed for intrafraction motion monitoring on conventional linacs. Magnetic resonance imaging (MRI) has been integrated with cobalt treatment units and more recently with linacs. In addition to hardware innovation, software development has played a substantial role in the development of motion monitoring methods based on respiratory motion surrogates and planar kV or Megavoltage (MV) imaging that is available on standard equipped linacs. In this paper, we review and compare the different intrafraction motion monitoring methods proposed in the literature and demonstrated in real-time on clinical data as well as their possible future developments. We then discuss general considerations on validation and quality assurance for clinical implementation. Besides photon RT, particle therapy is increasingly used to treat moving targets. However, transferring motion monitoring technologies from linacs to particle beam lines presents substantial challenges. Lessons learned from the implementation of real-time intrafraction monitoring for photon RT will be used as a basis to discuss the implementation of these methods for particle RT.

Characterization of EBT3 radiochromic films for dosimetry of proton beams in the presence of magnetic fields

PURPOSE

Radiochromic film dosimetry is extensively used for quality assurance in photon and proton beam therapy. So far, GafchromicTM EBT3 film appears as a strong candidate to be used in future magnetic resonance (MR) based therapy systems. The response of Gafchromic EBT3 films in the presence of magnetic fields has already been addressed for different MR-linacs systems. However, a detailed evaluation of the influence of external magnetic fields on the film response and calibration curves for proton therapy has not yet been reported. This study aims to determine the dose responses of EBT3 films for clinical proton beams exposed to magnetic field strengths up to 1 T in order to investigate the feasibility of EBT3 film as an accurate dosimetric tool for a future MR particle therapy system (MRPT).

METHODS

The dosimetric characteristics of EBT3 films were studied for a proton beam passing through magnetic field strengths of B = 0, 0.5, and 1 T. Absorbed dose calibration and measurements were performed using clinical proton beams in the nominal energy range of 62.4-252.6 MeV. Irradiations were done using an in-house developed PMMA slab phantom placed in the center of a dipole research magnet. Monte Carlo (MC) simulations using the GATE/Geant4 toolkit were performed to predict the effect of magnetic fields on the energy deposited by proton beams in the phantom. Planned and measured doses from 3D box cube irradiations were compared to assess the accuracy of the dosimetric method using EBT3 films with/without the external magnetic field.

RESULTS

Neither for the mean pixel value nor for the net optical density, any significant deviations were observed due to the presence of an external magnetic field (B ≤ 1T) for doses up to 10 Gy. Dose-response curves for the red channel were fitted by a three-parameter function for the field-free case and for B = 1T, showing for both cases an R-square coefficient of unity and almost identical fitting parameters. Independently of the magnetic field, EBT3 films showed an under-response as high as 8% in the Bragg peak region, similarly to previously reported effects for particle therapy. No noticeable influence of the magnetic field strength was observed on the quenching effect of the EBT3 films.

CONCLUSIONS

For the first time detailed absorbed dose calibrations of EBT3 films for proton beams in magnetic field regions were performed. Results showed that EBT3 films represent an attractive solution for the dosimetry of a future MRPT system. As film response functions for protons are not affected by the magnetic field strenght, they can be used for further investigations to evaluate the dosimetric effects induced due to particle beams bending in magnetic fields regions.

Technical Note: Effect of magnetic fields on the microdosimetry of carbon-ion beams

PURPOSE

To investigate the influence of magnetic fields on the microdosimetry of carbon-ion beams and the scaling effect of tissue equivalent proportional counter (TEPC) defined as the change of energy deposition in a TEPC from that in a microscopic scale region of interest due to the presence of a magnetic field in combination with the TEPC larger physical dimensions.

METHODS

Geant4-based Monte Carlo simulations were conducted to calculate the microdosimetric quantities for carbon-ion beams with different initial energies (10-290 MeV/u) under magnetic fields of various strengths (0.5-3 T). The calculations were performed for a 1 μm spherical volume made of tissue, and for spherical TEPCs of 1 and 10 mm in diameter. Then, values of dose-averaged lineal energy (y_D ) were acquired for the different scenarios to analyze the effect of magnetic fields on the microdosimetry of carbon-ion beams and the scaling effect of TEPC.

RESULTS

The y_D values and lineal energy spectra in the 1 μm spherical tissue volume for the scenarios without magnetic field and with magnetic fields of different strengths and directions remained nearly the same for the various energy carbon-ion beams. However, compared with those of the 1 μm spherical tissue volume, an increase of of y_D values and an obvious shift of the lineal energy spectra for the TEPCs of 1 and 10 mm in diameter under magnetic fields were found.

CONCLUSIONS

The application of magnetic fields under 3 T has no significant influence on the microdosimetric results of carbon-ion beams. However, there is definitely a scaling effect when using TEPC for microdosimetric study, which alters the reading of TEPC in the presence of magnetic fields. Novel methods to correct the reading of TEPC or scaling effect-resistant microdosimetric measurement detectors are urgently needed to perform experimental microdosimetric studies under magnetic fields.

Influence of a perpendicular magnetic field on biological effectiveness of carbon-ion beams

Purpose: Our previous study revealed that the application of a magnetic field longitudinal to a carbon-ion beam of 0.1 ≤ B_//≤ 0.6 T enhances the biological effectiveness of the radiation. The purpose of this study is to experimentally verify whether the application of a magnetic field perpendicular to the beam also alters the biological effectiveness. Methods and materials: Most experimental conditions other than the magnetic field direction were the same as those used in the previous study to allow comparison of their results. Human cancer and normal cells were exposed to low (12 keV/μm) and high (50 keV/μm) linear energy transfer (LET) carbon-ion beams under the perpendicular magnetic fields of B⊥ = 0, 0.15, 0.3, or 0.6 T generated by a dipole magnet. The effects of the magnetic fields on the biological effectiveness were evaluated by clonogenic cell survival. Doses that would result in the survival of 10%, D₁₀s, were determined for the exposures and analyzed using Student's t-tests. Results: For both cancer and normal cells treated by low- and high-LET carbon-ion beams, the D₁₀s measured in the presence of the perpendicular magnetic fields of B⊥ ≥ 0.15 T were not statistically different (p ≫ .05) from the D₁₀s measured in the absence of the magnetic fields, B⊥ = 0 T. Conclusions: Exposure of human cancer and normal cells to the perpendicular magnetic fields of B⊥ ≤ 0.6 T did not alter significantly the biological effectiveness of the carbon-ion beams, unlike the exposure to longitudinal magnetic fields of the same strength. Although the mechanisms underlying the observed results still require further exploration, these findings indicate that the influence of the magnetic field on biological effectiveness of the carbon-ion beam depends on the applied field direction with respect to the beam.

In vitro biological response of cancer and normal tissue cells to proton irradiation not affected by an added magnetic field

To optimize beam delivery and conformality of proton therapy, MRI integration has been proposed. Therefore, we investigated if proton irradiation in a magnetic field would change biological responses. Our data in cancer cell lines and stem cell-derived organoid models suggest that a magnetic field does not modify the biological response.

Proton beam electron return effect: Monte Carlo simulations and experimental verification

Proton therapy (PT) is expected to benefit from integration with magnetic resonance (MR) imaging. However, the magnetic field distorts the dose distribution and enhances the dose at tissue-air interfaces by the electron return effect (ERE). The objectives were (a) to provide experimental evidence for the ERE in proton beams and (b) to systematically characterise the dependence of the dose enhancement ratio (DER) on magnetic field strength, orientation, proton energy and voxel size by computer simulations. EBT3 films were irradiated with 200 MeV protons with and without a 0.92 T transverse field of a permanent magnet to determine the DER at effective measurement depths of 0.156 and 0.467 mm from an air interface. High-resolution Monte Carlo simulations were performed to reproduce the irradiation experiments and to calculate the DER for proton energies between 50-200 MeV and magnetic field strengths between 0.35-3 T as function of distance from the air interface. Voxel sizes of 0.05, 0.5 and 1 mm were analysed. DERs of (2.2  ±  0.4)% and (0.5  ±  0.6)% were measured at 0.156 and 0.467 mm from the air interface, respectively. Measurements and simulations agreed within 0.15%. For a 200 MeV proton beam, the maximum DER in 0.05 mm voxels increased with magnetic field strength from 2.6% to 8.2% between 0.35 and 1.5 T, respectively. For a 1.0 T magnetic field, maximum DER increased from 3.2% to 7.6% between 50 and 200 MeV, respectively. Voxel sizes of 0.5 and 1 mm resulted in maximum DER values of 2.6% and 1.4%, respectively. The ERE for proton beams in transverse magnetic fields is measurable. The local dose enhancement is significant, well predictable, decreases rapidly with distance from the air interface, and is negligible beyond 1 mm depth. Its impact on air-filled ionisation chambers and porous tissues (e.g. lung) needs to be considered.

Current state and future applications of radiological image guidance for particle therapy

In this review paper, we first give a short overview of radiological image guidance in photon radiotherapy, placing emphasis on the fact that linac based radiotherapy has outpaced particle therapy in the adoption of volumetric image guidance. While cone beam computed tomography (CBCT) has been an established technique in linac treatment rooms for almost two decades, the widespread adoption of volumetric image guidance in particle therapy, whether by means of CBCT or in-room CT imaging, is recent. This lag may be attributable to the bespoke nature and lower number of particle therapy installations, as well as the differences in geometry between those installations and linac treatment rooms. In addition, for particle therapy the so called shift invariance of the dose distribution rarely applies. An overview of the different volumetric image guidance solutions found at modern particle therapy facilities is provided, covering gantry, nozzle, C-arm, and couch-mounted CBCT as well different in-room CT configurations. A summary of the use of in-room volumetric imaging data beyond anatomy-based positioning is also presented as well as the necessary corrections to CBCT images for accurate water equivalent thickness calculation. Finally, the use of non-ionizing imaging modalities is discussed.

Integrating a low-field open MR scanner with a static proton research beam line: proof of concept

On-line image guidance using magnetic resonance (MR) imaging is expected to improve the targeting accuracy of proton therapy. However, to date no combined system exists. In this study, for the first time a low-field open MR scanner was integrated with a static proton research beam line to test the feasibility of simultaneous irradiation and imaging. The field-of-view of the MR scanner was aligned with the beam by taking into account the Lorentz force induced beam deflection. Various imaging sequences for extremities were performed on a healthy volunteer and on a patient with a soft-tissue sarcoma of the upper arm, both with the proton beam line switched off. T ₁-weighted spin echo images of a tissue-mimicking phantom were acquired without beam, with energised beam line magnets and during proton irradiation. Beam profiles were acquired for the MR scanner's static magnetic field alone and in combination with the dynamic gradient fields during the acquisition of different imaging sequences. It was shown that MR imaging is feasible in the electromagnetically contaminated environment of a proton therapy facility. The observed quality of the anatomical MR images was rated to be sufficient for target volume definition and positioning. The tissue-mimicking phantom showed no visible beam-induced image degradation. The beam profiles depicted no influence due to the dynamic gradient fields of the imaging sequences. This study proves that simultaneous irradiation and in-beam MR imaging is technically feasible with a low-field MR scanner integrated with a static proton research beam line.

Clinical implementations of 4D pencil beam scanned particle therapy: Report on the 4D treatment planning workshop 2016 and 2017

In 2016 and 2017, the 8th and 9th 4D treatment planning workshop took place in Groningen (the Netherlands) and Vienna (Austria), respectively. This annual workshop brings together international experts to discuss research, advances in clinical implementation as well as problems and challenges in 4D treatment planning, mainly in spot scanned proton therapy. In the last two years several aspects like treatment planning, beam delivery, Monte Carlo simulations, motion modeling and monitoring, QA phantoms as well as 4D imaging were thoroughly discussed. This report provides an overview of discussed topics, recent findings and literature review from the last two years. Its main focus is to highlight translation of 4D research into clinical practice and to discuss remaining challenges and pitfalls that still need to be addressed and to be overcome.

Evaluation of gold fiducial marker manual localisation for magnetic resonance-only prostate radiotherapy

BACKGROUND

The use of intraprostatic gold fiducial markers (FMs) ensures highly accurate and precise image-guided radiation therapy for patients diagnosed with prostate cancer thanks to the ease of localising FMs on photon-based imaging, like Computed Tomography (CT) images. Recently, Magnetic Resonance (MR)-only radiotherapy has been proposed to simplify the workflow and reduce possible systematic uncertainties. A critical, determining factor in the accuracy of such an MR-only simulation will be accurate FM localisation using solely MR images.

PURPOSE

The aim of this study is to evaluate the performances of manual MR-based FM localisation within a clinical environment.

METHODS

We designed a study in which 5 clinically involved radiation therapy technicians (RTTs) independently localised the gold FMs implanted in 16 prostate cancer patients in two scenarios: employing a single MR sequence or a combination of sequences. Inter-observer precision and accuracy were assessed for the two scenarios for localisation in terms of 95% limit of agreement on single FMs (LoA)/ centre of mass (LoA _CM) and inter-marker distances (IDs), respectively.

RESULTS

The number of precisely located FMs (LoA <2 mm) increased from 38/48 to 45/48 FMs when localisation was performed using multiple sequences instead of single one. When performing localisation on multiple sequences, imprecise localisation of the FMs (3/48 FMs) occurred for 1/3 implanted FMs in three different patients. In terms of precision, we obtained LoA _CM within 0.25 mm in all directions over the precisely located FMs. In terms of accuracy, IDs difference of manual MR-based localisation versus CT-based localisation was on average (±1 STD) 0.6 ±0.6 mm.

CONCLUSIONS

For both the investigated scenarios, the results indicate that when FM classification was correct, the precision and accuracy are high and comparable to CT-based FM localisation. We found that use of multiple sequences led to better localisation performances compared with the use of single sequence. However, we observed that, due to the presence of calcification and motion, the risk of mislocated patient positioning is still too high to allow the sole use of manual FM localisation. Finally, strategies to possibly overcome the current challenges were proposed.

Technical Note: Experimental verification of magnetic field-induced beam deflection and Bragg peak displacement for MR-integrated proton therapy

PURPOSE

Given its sensitivity to anatomical variations, proton therapy is expected to benefit greatly from integration with magnetic resonance imaging for online anatomy monitoring during irradiation. Such an integration raises several challenges, as both systems mutually interact. The proton beam will experience quasi-continuous energy loss and energy-dependent electromagnetic deflection at the same time, giving rise to a deflected beam trajectory and an altered dose distribution with a displaced Bragg peak. So far, these effects have only been predicted using Monte Carlo and analytical models, but no clear consensus has been reached and experimental benchmark data are lacking. We measured proton beam trajectories and Bragg peak displacement in a homogeneous phantom placed inside a magnetic field and compared them to simulations.

METHODS

Planar dose distributions of proton pencil beams (80-180 MeV) traversing the field of a 0.95 T NdFeB permanent magnet while depositing energy in a PMMA slab phantom were measured using EBT3 radiochromic films and simulated using the Geant4 toolkit. Deflected beam trajectories and the Bragg peak displacement were extracted from the measured planar dose distributions and compared against the simulations.

RESULTS

The lateral beam deflection was clearly visible on the EBT3 films and ranged from 1 to 10 mm for 80 to 180 MeV, respectively. Simulated and measured beam trajectories and Bragg peak displacement agreed within 0.8 mm for all studied proton energies.

CONCLUSIONS

These results prove that the magnetic field-induced Bragg peak displacement is both measurable and accurately predictable in a homogeneous phantom at 0.95 T, and allows Monte Carlo simulations to be used as gold standard for proton beam trajectory prediction in similar frameworks for MR-integrated proton therapy.

A pencil beam algorithm for magnetic resonance image-guided proton therapy

Purpose

The feasibility of magnetic resonance image (MRI)‐based proton therapy is based, among several other factors, on the implementation of appropriate extensions on current dose calculation methods. This work aims to develop a pencil beam algorithm (PBA) for dose calculation of proton beams within magnetic field regions of up to 3 T.

Methods

Monte Carlo (MC) simulations using the GATE 7.1/GEANT4.9.4p02 toolkit were performed to generate calibration and benchmarking data for the PBA. Dose distributions from proton beams in the clinical required energy range 60–250 MeV impinging on a 400 × 400 × 400 mm³ water phantom and transverse magnetic fields ranging from 0 to 3 T were considered. Energy depositions in homogeneous and heterogeneous phantoms filled with water, adipose, bone, and air were evaluated for proton energies of 80, 150, and 240 MeV, combining a trajectory calculation method and look‐up tables (LUT). A novel parametrization model, using independent tailed Gauss fitting functions, was employed to describe the nonsymmetric shape of lateral beam profiles. Integrated depth‐dose curves (IDD), lateral dose profiles, and two‐dimensional dose distributions calculated with the PBA were compared with results from MC simulations to assess the performance of the algorithm. A gamma index criterion of 2%/2 mm was used for analysis.

Results

A close to perfect agreement was observed for PB‐based dose calculations in water in magnetic fields of 0.5, 1.5, and 3 T. IDD functions showed differences between the PBA and MC of less than 0.1% before the Bragg peak, and deviations of 2–8% in the distal energy falloff region. Gamma index pass rates higher than 99% and mean values lower than 0.1 were encountered for all analyzed configurations. For homogeneous phantoms, only the full bone configuration offered deviations in the Bragg peak position of up to 1.7% and overestimations of the lateral beam spot width for high‐energy protons and magnetic field intensities. An excellent agreement between PBA and MC dose calculation was also achieved using slab‐like and lateral heterogeneous phantoms, with gamma index passing rates above 98% and mean values between 0.1 and 0.2. As expected, agreement reduced for high‐energy protons and high‐intensity magnetic fields, although results remained good enough to be considered for future implementation in clinical practice.

Conclusions

The proposed pencil beam algorithm for protons can accurately account for dose distortion effects induced by external magnetic fields. The application of an analytical model for dose estimation and corrections reduces the calculation times considerably, making the presented PBA a suitable candidate for integration in a treatment planning system.

Feasibility of MR-only proton dose calculations for prostate cancer radiotherapy using a commercial pseudo-CT generation method

A magnetic resonance (MR)-only radiotherapy workflow can reduce cost, radiation exposure and uncertainties introduced by CT-MRI registration. A crucial prerequisite is generating the so called pseudo-CT (pCT) images for accurate dose calculation and planning. Many pCT generation methods have been proposed in the scope of photon radiotherapy. This work aims at verifying for the first time whether a commercially available photon-oriented pCT generation method can be employed for accurate intensity-modulated proton therapy (IMPT) dose calculation. A retrospective study was conducted on ten prostate cancer patients. For pCT generation from MR images, a commercial solution for creating bulk-assigned pCTs, called MR for Attenuation Correction (MRCAT), was employed. The assigned pseudo-Hounsfield Unit (HU) values were adapted to yield an increased agreement to the reference CT in terms of proton range. Internal air cavities were copied from the CT to minimise inter-scan differences. CT- and MRCAT-based dose calculations for opposing beam IMPT plans were compared by gamma analysis and evaluation of clinically relevant target and organ at risk dose volume histogram (DVH) parameters. The proton range in beam's eye view (BEV) was compared using single field uniform dose (SFUD) plans. On average, a [Formula: see text] mm) gamma pass rate of 98.4% was obtained using a [Formula: see text] dose threshold after adaptation of the pseudo-HU values. Mean differences between CT- and MRCAT-based dose in the DVH parameters were below 1 Gy ([Formula: see text]). The median proton range difference was [Formula: see text] mm, with on average 96% of all BEV dose profiles showing a range agreement better than 3 mm. Results suggest that accurate MR-based proton dose calculation using an automatic commercial bulk-assignment pCT generation method, originally designed for photon radiotherapy, is feasible following adaptation of the assigned pseudo-HU values.

Future of medical physics: Real-time MRI-guided proton therapy

With the recent clinical implementation of real-time MRI-guided x-ray beam therapy (MRXT), attention is turning to the concept of combining real-time MRI guidance with proton beam therapy; MRI-guided proton beam therapy (MRPT). MRI guidance for proton beam therapy is expected to offer a compelling improvement to the current treatment workflow which is warranted arguably more than for x-ray beam therapy. This argument is born out of the fact that proton therapy toxicity outcomes are similar to that of the most advanced IMRT treatments, despite being a fundamentally superior particle for cancer treatment. In this Future of Medical Physics article, we describe the various software and hardware aspects of potential MRPT systems and the corresponding treatment workflow. Significant software developments, particularly focused around adaptive MRI-based planning will be required. The magnetic interaction between the MRI and the proton beamline components will be a key area of focus. For example, the modeling and potential redesign of a magnetically compatible gantry to allow for beam delivery from multiple angles towards a patient located within the bore of an MRI scanner. Further to this, the accuracy of pencil beam scanning and beam monitoring in the presence of an MRI fringe field will require modeling, testing, and potential further development to ensure that the highly targeted radiotherapy is maintained. Looking forward we envisage a clear and accelerated path for hardware development, leveraging from lessons learnt from MRXT development. Within few years, simple prototype systems will likely exist, and in a decade, we could envisage coupled systems with integrated gantries. Such milestones will be key in the development of a more efficient, more accurate, and more successful form of proton beam therapy for many common cancer sites.