Real-time image-guided treatment of mobile tumors in proton therapy by a library of treatment plans: a simulation study.

Purpose: To improve target coverage and reduce the dose in the surrounding organs-at-risks (OARs), we developed an image-guided treatment method based on a precomputed library of treatment plans controlled and delivered in real-time.

Methods: A library of treatment plans is constructed by optimizing a plan for each breathing phase of a four dimensional computed tomography (4DCT). Treatments are delivered by simulation on a continuous sequence of synthetic computed tomographies (CTs) generated from real magnetic resonance imaging (MRI) sequences. During treatment, the plans for which the tumor are at a close distance to the current tumor position are selected to deliver their spots. The study is conducted on five liver cases.

Results: We tested our approach under imperfect knowledge of the tumor positions with a 2 mm distance error. On average, compared to a 4D robustly optimized treatment plan, our approach led to a dose homogeneity increase of 5% (defined as ) in the target and a mean liver dose decrease of 23%. The treatment time was roughly increased by a factor of 2 but remained below 4 min on average.

Conclusions: Our image-guided treatment framework outperforms state-of-the-art 4D-robust plans for all patients in this study on both target coverage and OARs sparing, with an acceptable increase in treatment time under the current accuracy of the tumor tracking technology.