Real-Time Gated Proton Therapy: Commissioning and Clinical Workflow for the Hitachi System

Purpose To describe the commissioning of real-time gated proton therapy (RGPT) and the establishment of an appropriate clinical workflow for the treatment of patients. Methods and Materials Hitachi PROBEAT provides pencil beam scanning (PBS) proton therapy with an advanced onboard imaging system including real-time fluoroscopy. RGPT utilizes a matching score to provide instantaneous system performance feedback and quality control for patient safety. The CIRS Dynamic System combined with a Thorax Phantom or plastic water was utilized to mimic target motion. The OCTAVIUS was utilized to measure end-to-end dosimetric accuracy for a moving target across a range of simulated situations. Using this dosimetric data, the gating threshold was carefully evaluated and selected based on the intended treatment sites and planning techniques. An image-guidance workflow was developed and applied to patient treatment. Results Dosimetric data demonstrated that proton plan delivery uncertainty could be within 2 mm for a moving target. The dose delivery to a moving target could pass 3%/3mm gamma analysis following the commissioning process and application of the clinical work flow detailed in this manuscript. A clinical workflow was established and successfully applied to patient treatment utilizing RGPT. Prostate cancer patients with implanted platinum fiducials markers were treated with RGPT. Their target motion and gating signal data were available for intra-fraction motion analysis. Conclusions RGPT with the Hitachi System has been fully investigated and commissioned for clinical application. RGPT can provide advanced and reliable real-time image guidance to enhance patient safety and inform important treatment planning parameters, such as planning target volume margins and uncertainty parameters for robust plan optimization. RGPT improved the treatment of patients with prostate cancer in situations where intrafraction motion is more than defined tolerance.