Quantifying interplay effects in lung cancer IMPT: a comprehensive analysis of treatment planning parameter...

Precise dose delivery to the target is constrained by respiratory motion in intensity modulated proton therapy (IMPT) for lung cancer. This study aims to investigate the impact of treatment planning parameters on the lung cancer IMPT.

30 lung cancer patients treated at Shandong Cancer Hospital and institute were recruited in the study. A 4DCT dataset with 10 respiratory phases was reconstructed for each patient. The RayStation11B treatment planning system was used to create two-oblique-field IMPT plans. A prescription dose of 60 Gy (RBE) for 30 fractions was administered to 95% volume of the CTV. Five proton planning strategies were developed for each patient: (1) Range shifter (RS) plan: four plans were generated by varying range shifter thickness (0, 2, 3, and 5 cm) to change spot sizes; (2) Layer Spacing (LS) plan: four plans with different layer spacing (0.5, 1, 1.5 and 2 cm); (3) Spot Spacing (SS) plan: four plans with spot spacing variations (0.5, 1, 1.5 and 2 cm); (4) Repainting (RE) plan: layer repainting techniques with different numbers of repainting 1, 4 or 8 was adopted to the plan; (5) Ring plan: Dose fall-off was optimized using a ring structure around the target. 4D dynamic dose distributions (4DDDs) were calculated for plans created with various treatment planning parameters. Plan quality and dose-volume histogram (DVH) parameters for the target and organs at risk (OARs) were then analyzed.

For the RS plan, the D_95% of CTV, V₂₀ and V₅ of ipsilateral lung increased as the spot size became larger. The D_2% in RS5 plan was slightly higher than in the other three groups. The D_95% and D_2% in the target decreased as the layer spacing increased. The average value for the ELS2 group was about 3.8 Gy (RBE) higher than that of the ELS0.5 group (69.7 vs. 65.9 Gy (RBE)). The values for V₂₀ and V₅ of lung were similar across groups. Variations in spot spacing had slightly impact on D_95% for the target and V₂₀, V₅ for the ipsilateral lung. The effect on D_2% was more pronounced. The median D_95% values for the three groups gradually increased with the number of repainting. For the ipsilateral lung, the number of repainting had little impact on the doses of V₂₀ and V₅. For the ring plan, the nominal group had slightly higher D_95%, V₂₀, and V₅ values compared to the ring group. The D_2% in the nominal group was lower than that in the ring group, with average values of 65.8 and 67.6 Gy (RBE), respectively.

A systematic analysis was conducted in this study on the impact of spot size, LS, SS, layer repainting, and ring structure on the 4D robustness of IMPT plans for lung cancer patients. These five strategies demonstrated that beam spot size and layer spacing affected plan robustness, while spot spacing had relatively minor influence on robustness. The repainting technology can mitigate the interplay effect caused by respiratory motion. The application of ring structures affected the dose distribution of the moving target.