CBCT-based adaptive assessment workflow for intensity modulated proton therapy for head and neck cancer

Mariluz de Ornelas, Yihang Xu, Kyle Padgett, Ryder M. Schmidt, Michael Butkus, Tejan Diwanji, Gus Luciani, Jason Lambiase, Stuart Samuels, Michael Samuels, Nesrin Dogan

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Purpose: Anatomical changes and patient setup uncertainties during intensity modulated proton therapy (IMPT) of head and neck (HN) cancers demand frequent evaluation of delivered dose. This work investigated a cone-beam computed tomography (CBCT) and deformable image registration based therapy workflow to demonstrate the feasibility of proton dose calculation on synthetic computed tomography (sCT) for adaptive IMPT treatment of HN cancer. Materials and Methods: Twenty-one patients with HN cancer were enrolled in this study, a retrospective institutional review board protocol. They had previously been treated with volumetric modulated arc therapy and had daily iterative CBCT. For each patient, robust optimization (RO) IMPT plans were generated using 63 mm patient setup and 63% proton range uncertainties. The sCTs were created and the weekly delivered dose was recalculated using an adaptive dose accumulation workflow in which the planning computed tomography (CT) was deformably registered to CBCTs and Hounsfield units transferred from the planning CT. Accumulated doses from 63 mm/ 63% RO-IMPT plans were evaluated using clinical dose-volume constraints for targets (clinical target volume, or CTV) and organs at risk. Results: Evaluation of weekly recalculated dose on sCTs showed that most of the patient plans maintained target dose coverage. The primary CTV remained covered by the V95 . 95% (95% of the volume receiving more than 95% of the prescription dose) worst-case scenario for 84.5% of the weekly fractions. The oral cavity accumulated mean dose remained lower than the worst-case scenario for all patients. Parotid accumulated mean dose remained within the uncertainty bands for 18 of the 21 patients, and all were kept lower than RO-IMPT worst-case scenario for 88.7% and 84.5% for left and right parotids, respectively. Conclusion: This study demonstrated that RO-IMPT plans account for most setup and anatomical uncertainties, except for large weight-loss changes that need to be tracked throughout the treatment course. We showed that sCTs could be a powerful decision tool for adaptation of these cases in order to reduce workload when using repeat CTs.

Original languageEnglish (US)
Pages (from-to)29-41
Number of pages13
JournalInternational Journal of Particle Therapy
Issue number4
StatePublished - Mar 1 2021


  • Dose accumulation
  • Head
  • IMPT
  • Neck cancer

ASJC Scopus subject areas

  • Atomic and Molecular Physics, and Optics
  • Radiology Nuclear Medicine and imaging


Dive into the research topics of 'CBCT-based adaptive assessment workflow for intensity modulated proton therapy for head and neck cancer'. Together they form a unique fingerprint.

Cite this