1

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

gated proton treatment 
Medical Dosimetry Program at the University of Wisconsin-LaCrosse, WI 
ABSTRACT 
Keywords: 
Introduction 
The use of intensity modulated proton therapy (IMPT) has become common in the
treatment of chest and abdominal treatment sites due to its advantages over conventional
radiotherapy. Proton treatments spare healthy organs and provide a more conformal dose
distribution,1 but their finite range makes them sensitive to changes in patient anatomy.2  
Variations in patient setup and changes in anatomy can affect dose distribution, and impact target
coverage and sparing of organs at risk.3 To address these uncertainties, routine verification
scanning is needed to evaluate any changes in the current dose distribution from the original
treatment plan.4 Verification planning involves registering the verification scan to the original
planning scan and calculating dose on the new scan. Both rigid and deformable registrations are
used to transfer structures to the verification scan.2 Target coverages and organs at risk (OAR)
doses are displayed on a dose volume histogram (DVH) that is evaluated by the physician who
uses clinical judgement to determine the need for a replan.4 Modifications can be applied to
treatment plans throughout the course of treatment delivery to account for changes in target
volumes, normal structures, and patient contours.5 Replanning may be necessary at any point
throughout treatment, especially beyond 4 weeks,2 emphasizing the importance of an efficient
verification and replanning process to maintain plan quality. 
Target motion influences the accuracy of treatment delivery of IMPT, and efforts are
often made to mitigate or account for known target motion. The proton path length will change
as tissue densities change along that path.6 Motion interplay can also greatly affect the quality of
treatment delivery during spot-scanning proton therapy.7 Respiratory motion in proton therapy
can degrade dose distributions, especially with pencil beam scanning, but however, combining
rescanning and gating treatments can mitigate dose degradation at the expense of longer
treatment delivery times.8 A 4DCT is the standard for motion evaluation and treatment planning
for mobile targets. Imaging for 4DCT treatments results in 10 separate 3D CT volumes, each
representing a portion of the breathing cycle. The goal of respiratory gating is to treat only
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during the latent portion of respiration near expiration as this is more consistent and
reproducible.7 The treatment plan is generated on a 4DCT that includes only these phases of
respiration.1 Verification planning for phase-gated treatments requires the creation of this phase-
gated average prior to running theperforming the treatment plan verification workflow. 
Chest and abdominal treatment sites often suffer from target motion due to normal
breathing and require 4D phase gated treatment techniques to mitigate motion effects on
treatment accuracy. Tumor motion of the esophagus, pancreas, and liver is between 3-20 mm on
average resulting in the need for motion management during treatment delivery for these
treatment sites.1 Thoracic and abdominal treatment sites requiring 4D phase gated treatment often
require replanning throughout the course of treatment. Replanning is indicated for about 25% of
cases in motion management disease sites, therefore, weekly verifications are advised for
treatment sites requiring motion management.7 In an evaluation of replanning frequency by
Mundy et al,9 the replan rate for esophagus sites was 17%, and liver-pancreas-adrenal was 22%
of patients. The verification process disrupts clinical workflow and requires extensive clinical
resources. An efficient verification workflow is essential to manage the added clinical demands
of frequent verification planning. Automation of these processes can lead to increased efficiency
and decreased demand on clinical resources.
Adaptive radiation therapy (ART) is another development that would increase the
accuracy of IMPT treatment delivery. ART enables monitoring and modification of the treatment
plan to maximize target dose and minimize normal tissue dosage.5 Online ART is performed in
the treatment room immediately prior to treatment delivery and is particularly suitable for
treatment areas with anticipated adaption needs, such as intra-abdominal sites.5 Efficient
workflows are crucial for implementing online adaptive protocols in radiotherapy practices,
which involve complex and labor-intensive tasks such as imaging, assessment, replanning, and
quality assurance.5 Decreased efficiency can lead to targeting inaccuracies due to changes
between initial imaging and beam delivery.1 This process needs to be efficient and requires
specialized automation tools. The creation of a phase-gated average scan is a manual process,
making phase-gated treatment plans incompatible with current automation software.  
Routine verification planning requires efficient workflows that utilize automated
software. The problem is that the verification process for patients receiving phase-gated proton
treatment requires the creation of a new phase-gated average scan which is time-consuming,
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requires additional clinical resources, and is incompatible with current software used for
automatic verification planning. 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 to ensure determine ifthat the results were within clinically acceptable standards. This
study would allow for increased efficiency in verification planning for phase-gated proton
treatments as well as create compatibility with automatic verification planning software which
will be essential for future adaptive planning capabilities. Researchers tested the hypothesis that
the target coverage (V95%) on a single-phase verification plan will be within 5% of the target
coverage (V95%) on a phase-gated average verification plan. 
Methods and Materials 
Results 
Discussion 
Conclusion 
Acknowledgements 
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References 
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uncertainties in proton beam radiotherapy for gastrointestinal cancers. J of Gastrointest
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