Streamlining the image-guided radiotherapy process for proton beam therapy

Objectives:
This work evaluated the on-treatment imaging workflow in the UK’s first proton beam therapy (PBT) centre, with a view to reducing times and unnecessary imaging doses to patients.
Methods:
Imaging dose and timing data from the first 20 patients (70% paediatrics, 30% TYA/adult) treated with PBT using the initial image-guided PBT (IGPBT) workflow of a 2-dimensional kilo-voltage (2DkV), followed by cone-beam computed-tomography (CBCT) and repeat 2DkV was included. Pearson correlations and Bland-Altman analysis were used to describe correlations between 2DkV and CBCT images to determine if any images were superfluous.
Results:
229 treatment sessions were evaluated. Patient repositioning following the initial 2DkV (i2DkV) was required on 19 (8.3%) fractions. This three-step process resulted in an additional mean imaging dose of 3.4 mGy per patient, and 5.1 minutes on the treatment bed for the patient, over a whole course of PBT, compared to a two-step workflow (removing the i2DkV image). Correspondence between the mean displacements from i2DkV and CBCT was high, with R = 0.94, 0.94 and 0.80 in the anteroposterior, superiorinferior and right-left directions, respectively. Bland-Altman analysis showed very little bias and narrow limits of agreement.
Conclusions:
Removing the i2DkV, streamlining to a two-step workflow, would reduce treatment times and imaging dose, and has been implemented as standard verification protocol. For challenging cases (e.g. paediatric patients under GA), further investigations are required before the three-step workflow can be modified.