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Background and purpose: There is no consensus about an ideal robust optimization (RO) strategy for proton therapy of targets with large intra-fractional motion. We investigated the plan robustness of different RO strategies regarding setup/range errors, interplay effects and interfractional anatomical changes. Materials and methods: For eight non-small cell lung cancer patients with primary and/or nodal clinical target volume (CTVp/CTVn) with motion >5mm, different RO approaches were investigated: 3DRO considering the average CT (AvgCT) with a target density override, 4DRO considering three/all 4DCT phases, and 4DRO considering the AvgCT and three/all 4DCT phases. Realistic interplay scenarios were reconstructed based on patient breathing and machine logfile data for deliveries with/without layered rescanning. Robustness against setup/range errors, interplay effects and interfractional anatomical changes were analyzed for target coverage and OAR sparing. Results: All nominal plans fulfilled the clinical requirements, while 4DRO without AvgCT generated the most conformal dose distributions. Robustness against setup/range errors was best for 4DRO with AvgCT. No RO strategy was sufficient in countervailing fraction-wise dose distortions caused by interplay effects. Irrespective of rescanning, target coverage was restored in all cases when accumulating four interplay scenarios. 4DRO with AvgCT showed higher CTVp robustness against interfractional changes, but plan adaptations are necessary for all RO strategies in case of relevant anatomical changes. Conclusion: All RO strategies are clinically acceptable but exhibit equally low robustness against interplay effects. To ensure fraction-wise target coverage, additional motion mitigation is required for CTVs with large motion amplitudes and interfractional changes need to be monitored.

Background: We analyse the benefit of 4D robust plan optimization (RO) for proton therapy treatments of NSCLC patients with pronounced breathing-induced anatomical variations. Methods: Eight NSCLC patients with relevant maximal intrafractional motion of the primary (CTVp; 5.6-24.5mm) and/or nodal CTV (CTVn; 5.8-17.3mm) on the planning 4DCT (pCT) were included. We optimized three robust normo-fractionated plans with a criterion of 5mm setup and 3.5%+2mm range uncertainty: RO on the AverageCT with iGTVp density override (3DRO); RO on the AverageCT and three 4DCT phases (4DRO3); and RO on the AverageCT and all eight 4DCT phases (4DRO8). Setup and range error scenarios were analysed on the pCT. To assess robustness against intra- and inter-fractional changes, 4D doses were calculated on the pCT and up to two control 4DCTs (cCTs) assuming equal weights between breathing phases. Interplay effects were simulated on the pCT from patient breathing signals and machine logfiles of plan deliveries with and without 5 layered rescans. Fractionation effects were emulated by accumulating four interplay scenarios with different starting times. Results: All nominal plans fulfilled target coverage (D98%>95%) and OAR sparing; CTVp/CTVn coverage failed setup and range robustness in 12%/35% (3DRO), 14%/18% (4DRO3) and 13%/20% (4DRO8) of the scenarios (Fig1a), respectively. 4D dose target coverage on the pCT was >94% for all plans; interfractional changes in the cCTs reduced the CTVp coverage by about 2pp (Fig1b). Interplay analyses (Fig1c) revealed a mean CTVp/CTVn coverage loss by 3.4pp/2.4pp, 3.0pp/2.3pp, and 2.9pp/3.2pp in single scenarios of 3DRO, 4DRO3 and 4DRO8 plans, respectively. D98% values were improved on average by 1.0pp with rescanning, but were even worsened in some scenarios. Irrespective of rescanning, the simulated fractionation fullfilled the target coverage in all cases. Conclusion: 3DRO and 4DRO showed similar robustness against different motion effects. 4DRO provides benefits for some patients, but 3DRO demands less workload.

Purpose/Objective The inclusion of breathing-induced variation using 4D robust plan optimization (RO) may yield more robust proton plans for non-small cell lung cancer (NSCLC) patients. Here, we analysed the benefit of 4DRO in terms of robustness against different motion effects. Material/Methods Five NSCLC patients with relevant intrafractional motion in the primary (CTVp; on average 3.2-11.1mm) and nodal clinical target volumes (CTVn; 0.9-7.4mm) were included. CTVs and organs at risk (OARs) were contoured on the planning (pCT) and up to two control 4DCTs (cCT). In RayStation 7.99 (RaySearch, Sweden), we optimized three robust normo-fractionated plans [dose: 66Gy(RBE)]with our clinical criteria of 5mm setup and 3.5%+2mm range uncertainty: RO on the average CT with density override of the primary integral gross tumour volume (3DRO); RO on the average, minimum, maximum and mid inspiration CT image (4DRO3); and RO on the average CT and all eight 4DCT phases (4DRO8). On each of the average, minimum and maximum inspiration pCT, 16 setup and range error scenarios were analysed. To assess the influence of intrafractional changes, a 4D dose was calculated for the pCT and compared to those for the cCTs assuming equal weights of all breathing phases. Interplay effects were simulated by 4D dynamic dose (4DDD) scenarios on the pCT using a logfile-based dose reconstruction with machine logfiles from mock treatments with and without 5 layered rescans and the breathing signals from 4DCT acquisition. To account for a possible fractionation effect within the first fractions, we accumulated 4DDD scenarios with 4 different starting times. Results All nominal plans fulfilled target coverage (D98%>95%) and OAR sparing; 3DRO achieved lower mean lung dose [up to 0.3 Gy(RBE)] in 4 patients and lower V5Gy of contralateral lung (up to 4pp). CTVp/CTVn coverage failed setup and range robustness on average in 7%/17% (3DRO), 9%/10% (4DRO3) and 9%/12% (4DRO8) of the scenarios, respectively. 4D dose target coverage on the pCT remained >97% and within 0.5pp difference to the nominal results for both CTVp and CTVn for all planning strategies; however, interfractional changes in the cCTs reduced mainly the CTVp coverage by about 2.5pp, 2.7pp and 2.5pp in the case of 3DRO, 4DRO3 and 4DRO8 plans, respectively. Compared to the nominal plans, single 4DDD scenarios showed a larger mean loss of CTVp/CTVn coverage in 3DRO plans (2.9pp/2.0pp) than in 4DRO plans (4DRO3: 2.2pp/1.6pp, 4DRO8: 2.2pp/1.9pp). Rescanning improved the D98% values by less than 1pp on average, but was even worse for single scenarios. Irrespective of rescanning, target coverage was restored to clinical acceptance (>95%) in all cases when considering potential fractionation on the pCT. Conclusion 4DRO provided superior robustness for target coverage in some patients. However, 3DRO demands less workload, offers better healthy lung sparing and yields similar interplay effect reduction when combined with rescanning.