Radiation therapy of upper gastrointestinal cancers with scanned proton beams : A treatment planning study

• Proton beam therapy (PBT), using scanned beams, is an emerging modality used for the treatment of cancer. The clinical advantages of PBT, compared to commonly used photon beam therapy, have been demonstrated in different studies. However, the techniques used for planning and delivering treatments with photon beams have gradually been improved over the years. With the introduction of PBT in the clinic, guidelines to select patients to photon- or proton-beam therapy are indispensable.A simple approach used for selecting patients for PBT is based on the patient age. The paediatric patient group is considered to be the most radiosensitive and, therefore, in larger need of RT techniques that provide improved sparing of the organs at risk (OARs). With the increasing number of cancer clinics with access to PBT, combined with the constant clinical need of reducing the frequency of acute and late toxicities, there has been an increased use of PBT also for adult patients. At present, there is only limited clinical follow-up data available regarding the outcome of PBT for different tumour sites, in particular for extra-cranial tumours. The use of photon beams for such cancer treatments is, on the other hand, well-established. Therefore, the expected benefit of using proton beams in cancer therapy can be translated from the results obtained in the clinical experience attained from photon-beam treatments. The evaluation of the different uncertainties influencing the radiotherapy (RT) of different tumour sites carried out with photon- or proton-beams, will also create an improved understanding of the feasibility of treating cancer with scanned proton beams instead of with photon beams. The comparison of two distinct RT modalities is normally performed by studying the calculated dose distributions superimposed on the patient CT images and by evaluating the dosimetric values obtained from the dose volume histograms (DVHs). The dosimetric evaluation can be complemented with treatment outcome predictions in terms of local disease control and normal tissue toxicity. In this regard, radiobiological models can be an indispensable tool for the prediction of the outcome of cancer treatments performed with different types of ionising radiation. These estimates can in turn be used in the decision process for selecting patients for treatments with a specific RT modality.This thesis consists of five articles. In these studies, treatment plans for RT with scanned proton-beams have been prepared and compared with clinical plans used for photon-beam based RT. For this purpose, dosimetric and biological-model based evaluations of these plans were performed. These studies were carried out for two distinct upper gastrointestinal (GI) cancers, namely, gastric cancer (GC) and liver metastases. RT treatments with both conventional fractionation schemes (implemented in the planning for the GC treatments) and hypofractionated regimens (implemented in the planning for the liver metastases cases) were considered. For the GC cases, the impact of changes in tissue density, resulting from a variable gas content (which can be observed inter-fractionally), was investigated. Proton therapy was found to provide the possibility to reduce the doses given to normal tissues surrounding the target volumes, compared to photon RT. This dose reduction with PBT resulted in reduced risks for both treatment-induced normal tissue toxicities and secondary malignancies. The impact of the introduced density changes on the dose distributions were found to be more pronounced for the PBT plans, if plan robustness approaches were disregarded. The findings presented in this thesis can be of clinical importance in the selection process between different RT modalities.

Ämnesord

NATURVETENSKAP  -- Fysik (hsv//swe)

NATURAL SCIENCES  -- Physical Sciences (hsv//eng)

Nyckelord

Treatment planning

gastric cancer

liver metastases

photon beam therapy

proton beam therapy

dosimetric comparison

normal tissue complication probability

risk of radiation-induced secondary cancer

patient selection

Medical Radiation Physics

medicinsk strålningsfysik

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