LAUSR

PURPOSE In proton therapy, dose distributions are currently often conformed to organs at risk (OARs) using the less sharp dose fall-off at the lateral beam edge to reduce the effects of uncertainties in the proton range. However, range uncertainty reductions may make greater use of the sharper dose fall-off at the distal beam edge feasible, potentially improving OAR sparing. We quantified the benefits of such novel beam arrangements. METHODS For each of ten brain or skull base cases, five treatment plans robust to 2 mm setup and 0-4% range uncertainty were created for the traditional clinical beam arrangement and a novel beam arrangement making greater use of the distal beam edge to conform the dose distribution to the brainstem. Metrics including the brainstem normal tissue complication probability (NTCP) with the endpoint of necrosis were determined for all plans and all setup and range uncertainty scenarios. RESULTS For the traditional beam arrangement, reducing the range uncertainty from the current level of approximately 4% to a potentially achievable level of 1% reduced the brainstem NTCP by up to 0.9 percentage points in the nominal and up to 1.5 percentage points in the worst-case scenario. Switching to the novel beam arrangement at 1% range uncertainty improved these values by a factor of 2, i.e., to 1.8 percentage points and 3.2 percentage points, respectively. The novel beam arrangement achieved a lower brainstem NTCP in all cases starting at a range uncertainty of 2%. CONCLUSION The benefits of novel beam arrangements may be of the same magnitude or even exceed the direct benefits of range uncertainty reductions. Indirect effects may therefore contribute markedly to the benefits of reducing proton range uncertainties. This article is protected by copyright. All rights reserved.