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Online adaptive proton therapy (APT) is an ideal solution theoretically,which however is challenging to proton clinics. Although multiple groups havebeen endeavoring to develop online APT technology, there is a concern in theradiotherapy community about the necessity of online APT because of its unknownimpact on treatment outcomes. Hence, we have performed a retrospective study toinvestigate the potential clinical effects of online APT for HN cancer patientsin relative to the current offline APT via simulations. To mimic an online APTtreatment course, we have recalculated and evaluated the actual dose of thecurrent treatment plan on patient actual treatment anatomy captured by conebeam CT for each fraction. The cumulative dose of simulated online APT courseswas compared to actual offline APT courses and the initially designed treatmentplan dose. For patients 1 and 2, the simulated online ART course maintained arelatively higher CTV dose coverages than the offline ART course, particularlyfor CTV-Low, which led to an improvement of 2.66% and 4.52% in TCP of CTV-Low.For patients 3 and 4, with clinically comparable CTV dose coverages, thesimulated online ART course achieved better OAR sparing than the offline ARTcourse. The mean doses of right parotid and oral cavity were decreased from29.52 Gy relative biological effectiveness (RBE) and 41.89 Gy RBE to 22.16 GyRBE and 34.61 Gy RBE for patient 3, leading to a reduce of 1.67% and 3.40% inNTCP for the two organs. Compared to the current clinical practice, theretrospective study indicated that online APT tended to spare more normaltissues by achieving the clinical goal with merely half of the positionaluncertainty margin. Future studies are needed to help identify the patientswith large potential benefits prior to treatment to conserve scarce clinicalresources.

A Retrospective Study on the Investigation of Potential Clinical Benefits of Online Adaptive Proton Therapy for Head and Neck Cancer