Robust Proton Pencil Beam Scanning Treatment Planning for Rectal Cancer Radiation Therapy

Purpose: To investigate, in a treatment plan design and robustness study, whether proton pencil beam scanning (PBS) has the potential to offer advantages, relative to inter-fraction uncertainties, over photon volumetric modulated arc therapy (VMAT) in a locally advanced rectal cancer patient population. Methods and Materials: Ten patients received a planning CT scan, followed by an average of 4 weekly offline CT verification CT scans, which were rigidly co-registered to the planning CT. Clinical PBS plans were generated on the planning CT, using a single-field uniform-dose technique with single-posterior and parallel-opposed (LAT) fields geometries. The VMAT plans were generated on the planning CT using 2 6-MV, 220 degrees coplanar arcs. Clinical plans were forward-calculated on verification CTs to assess robustness relative to anatomic changes. Setup errors were assessed by forward-calculating clinical plans with a +/- 5-mm (left-right, anterior-posterior, superior-inferior) isocenter shift on the planning CT. Differences in clinical target volume and organ at risk dose-volume histogram (DHV) indicators between plans were tested for significance using an appropriate Wilcoxon test (P<.05). Results: Dosimetrically, PBS plans were statistically different from VMAT plans, showing greater organ at risk sparing. However, the bladder was statistically identical among LAT and VMAT plans. The clinical target volume coverage was statistically identical among all plans. The robustness test found that all DVH indicators for PBS and VMAT plans were robust, except the LAT's genitalia (V5, V35). The verification CT plans showed that all DVH indicators were robust. Conclusions: Pencil beam scanning plans were found to be as robust as VMAT plans relative to interfractional changes during treatment when posterior beam angles and appropriate range margins are used. Pencil beam scanning dosimetric gains in the bowel (V15, V20) over VMAT suggest that using PBS to treat rectal cancer may reduce radiation treatment-related toxicity. (C) 2016 Elsevier Inc. All rights reserved.