Abstract 4D workshop 2017

Title: Combined influence of plan modulation and intra-fractional motion by pancreatic

patients treated with charged particles

Authors: V.Batista1,6, D.Richter2,4, N.Chaudhri3,6, P.Naumann 1,6, K. Herfarth1,6, O. Jäkel 3,5,6

1 University Clinic of Heidelberg, Heidelberg, Germany; 2 University Clinic of Erlangen, Erlangen, Germany; 3 Heidelberg
Ion-Beam Therapy Center, Heidelberg, Germany; 4 GSI Helmholtz Centre for Heavy Ion Research, Darmstadt, Germany 5
German Cancer Research Center, Div. Medical Physics in Radiation Oncology, Heidelberg, Germany 6 Heidelberg Institute
for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), 69120 Heidelberg, Germany

Background & Aim: Uncertainties associated with beam delivery to moving organs
compromise the accuracy of the treatment. This study assesses the combined impact of
intrafractional anatomical changes and the degree of modulation of the dose distribution in
pancreatic patients treated with scanned charged particles. Our scope is, to define the potential
source of uncertainties, quantify their effect, and define clinically feasible strategies towards
their reduction.

Material & methods: The study included 14 patients with a planning CT and a 4DCT scan,
treated at our facility with charged particles (protons or 12C). Treatment plans were optimized
using the Treatment Planning System (TPS) Syngo® RT Planning. Using the TPS TRiP4D
the pre-treatment dose distribution under motion was simulated and the delivered dose was
reconstructed for some of the treatment fractions. The volume receiving at least 95% of the
prescribed dose (V95CTV) and the target dose homogeneity (HCTV=D5-D95) were
quantified. The results from the 4D dose calculations including the interplay effect were
compared with dose distributions in the static case. The concept of modulation index was
introduced to quantify the degree of dose modulation of plans, and correlated with the
obtained dose distributions.

Results: The induced breathing motion together with a dynamic beam delivery affects the
dose distribution in terms of homogeneity and target coverage. This effect is stronger
(∆V95CTV > 10%) for patients with tumor motion amplitude superior to 5 mm and a highly
modulated dose distribution intra- and inter-fields. The modulation index showed that
different optimizers produce plans with contrasting distribution of the number of particles,
resulting in unlike robustness against range and positioning uncertainties.

Conclusions: Under internal motion, the use of homogeneous plans, multiple beams, and
robust beam entrance directions, might results in dose distributions exhibiting an attenuated
decrease of the dose homogeneity and target coverage when compared with the static plan.