1

A comparison of single-phase and phase-gated average verification planning for proton

radiotherapy
Katelyn Knoepke, BS, R.T.(R)(T), Jennifer DeWeese, BS, R.T.(R)(T), Joseph Spencer, BS, R.T.
(R)(T)(CT), Nishele Lenards, PhD, CMD, R.T.(R)(T), FAAMD, Ashley Hunzeker, MS, CMD,
Jedediah E. Johnson, PhD
I. Abstract
II. Introduction
A. PI: Proton beam advantages, sensitivity to patient changes, CT verification for
treatment accuracy and adjustments. (Reference: Deiter et al,1 Knäusl et al,2
Tryggestad et al,3 Hu et al,4 Smolders et al,5 Evans et al,6 Green et al,7 Gelover et al8)
B. PII: Challenges due to respiratory motion, interplay effects and dose distribution
issues. (Reference: Knäusl et al,2 Tryggestad et al,3 Smolders et al,5 Gut et al,9 Tassti el
al10)
C. PIII: 4DCT imaging for target motion, respiratory gating for interplay effects.
(Reference: Tryggestad et al,3 Gelover et al,8 Gut et al,9 Tassti el al10)
D. PIV: The need for efficiency and optimization, adaptive radiation therapy, and
treatment accuracy while minimizing normal tissue exposure during hypofractionated
treatments. (Reference: Deiter et al,1 Tryggestad et al,3 Hu et al,4 Green et al,7
Paganetti et al11)
E. PV: Summarize introduction points.
1. Problem: The problem is that the verification process for phase-gated treatments
requires the creation of a new phase-gated average scan which is time consuming,
and incompatible with current workflows utilizing automated software.
2. Purpose: The purpose of this study was to compare target coverage reported on
phase-gated average verification plans to target coverage on single-phase
verification plans using the same plan to determine whether a single-phase
verification is an acceptable surrogate.
3. Hypothesis: The first research hypothesis (H1) is that the target coverage
(specified as V95%) on a single full exhale phase verification plan will be within
5% of the target coverage (V95%) on a phase-gated average verification plan for all
sites based on evaluation of rigid, deformable, and newly created target contours.
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Also, this will be true within each treatment site individually, as well as within
groups based on replan requirement.
III. Materials and Methods
A. PI: Study selection
1. Patient selection criteria
a. Inclusion criteria (4D treatments)
b. Exclusion criteria (not 4D treatments)
2. Study Population
a. Number of patients (18)
b. 4D lung patients (6)
c. 4D liver patients (5)
d. 4D esophagus patients (7)
B. PII: Study Design
1. 4D verification with phase gated average scan
a. MIM workflow
b. Eclipse import and verification plan process
C. PIII: Study Design
1. Single 50-phase scan
a. MIM workflow
b. Eclipse import and verification plan process
D. PIV: Plan Comparison
1. Physician review and contour modification
E. PV: Physician involvement
1. New CTV contour
a. original phase-gated average data set
b. 50-phase data set
2. Physician review
F. PVI: Data Collection and Statistical Analysis
1. Dose statistics
2. T-test for dependent means
3. P < 0.05 is considered statistically significant
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IV. Results
A. Quantitative Analysis
1. All treatment sites (Table 1, Table 2, Figure 1)
a. Rigid CTV contour (n=30): mean difference is -0.46% ± 1.1% (p=0.030)
b. Deformable CTV contour (n=30): mean difference is –0.13% ± 1.7%
(p=0.683)
c. New phase-gated CTV contour (n=20): mean difference is –0.63% ± 1.3%
(p=0.471)
d. New phase-gated vs. New 50-phase contour (n=20): mean difference is 0.45%
± 1.3% (p=0.139)
e. Target coverage (V95%) is within ± 5% for all contours
2. Lung (Figure 2)
a. Rigid CTV contour (n=7): mean difference is –1.72% ± 1.8% (p= 0.043)
b. Deformable CTV contour (n=7): mean difference is -1.13%± 2.2% (p=0.220)
c. New phase-gated CTV contour (n=7): mean difference is –1.67% ± 1.9%
(p=0.057)
d. New phase-gated vs. New 50-phase contour (n=7): mean difference is –1.08%
± 2.2%. (p=0.234)
e. Target coverage (V95%) is within ± 5% for all contours
3. Liver (Figure 3)
a. Rigid CTV contour (n=10): mean difference is 0.03% ± 0.2% (p= 0.593)
b. Deformable CTV contour (n=10): mean difference is 0.94% ± 1.3% (p=
0.052)
c. Target coverage (V95%) is within ± 5% for all contours
4. Esophagus (Figure 4)
a. Rigid CTV contour (n=13): mean difference is –0.16% ± 0.3% (p=0.053)
b. Deformable CTV contour (n=13): mean difference is –0.41% ± 1.3%
(p=0.288)
c. New phase-gated CTV contour (n=13): mean difference is –0.07% ± 0.3%
(p=0.328)
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d. New phase-gated vs. New 50-phase contour (n=13): mean difference is –

0.12% ± 0.3%. (p=0.124)
e. Target coverage (V95%) is within ± 5% for all contours
5. Replan (Figure 5)
a. Rigid CTV contour (n=7): mean difference is –0.75% ± 1.1% (p= 0.120)
b. Deformable CTV contour (n=7): mean difference is -1.02%± 2.4% (p=0.313)
c. New phase-gated CTV contour (n=8): mean difference is –1.34% ± 1.9%
(p=0.079)
d. New phase-gated vs. New 50-phase contour (n=8): mean difference is –0.65%
± 2.0%. (p=0.379)
e. Target coverage (V95%) is within ± 5% for all contours
6. No Replan (Figure 6)
a. Rigid CTV contour (n=20): mean difference is –0.15% ± 0.4% (p= 0.088)
b. Deformable CTV contour (n=20): mean difference is 0.38% ± 1.1% (p=0.138)
c. New phase-gated CTV contour (n=12): mean difference is –0.16% ± 0.5%
(p=0.313)
d. New phase-gated vs. New 50-phase contour (n=12): mean difference is –
0.32% ± 0.7%. (p=0.137)
e. Target coverage (V95%) is within ± 5% for all contours
B. Qualitative Analysis
1. Physician review process
2. Results within each site group
a. Lung
b. Liver
c. Esophagus
V. Discussion
VI. Conclusion
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