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Morphological changes that may arise through a treatment course are probably one of the most significant sources of range uncertainty in proton therapy. Non-invasive in-vivo treatment monitoring is useful to increase treatment quality. The INSIDE in-beam Positron Emission Tomography (PET) scanner performs in-vivo range monitoring in proton and carbon therapy treatments at the National Center of Oncological Hadrontherapy (CNAO). It is currently in a clinical trial (ID: NCT03662373) and has acquired in-beam PET data during the treatment of various patients. In this work we analyze the in-beam PET (IB-PET) data of eight patients treated with proton therapy at CNAO. The goal of the analysis is twofold. First, we assess the level of experimental fluctuations in inter-fractional range differences (sensitivity) of the INSIDE PET system by studying patients without morphological changes. Second, we use the obtained results to see whether we can observe anomalously large range variations in patients where morphological changes have occurred. The sensitivity of the INSIDE IB-PET scanner was quantified as the standard deviation of the range difference distributions observed for six patients that did not show morphological changes. Inter-fractional range variations with respect to a reference distribution were estimated using the Most-Likely-Shift (MLS) method. To establish the efficacy of this method, we made a comparison with the Beam’s Eye View (BEV) method. For patients showing no morphological changes in the control CT the average range variation standard deviation was found to be 2.5 mm with the MLS method and 2.3 mm with the BEV method. On the other hand, for patients where some small anatomical changes occurred, we found larger standard deviation values. In these patients we evaluated where anomalous range differences were found and compared them with the CT. We found that the identified regions were mostly in agreement with the morphological changes seen in the CT scan.

Objective: We introduce a new treatment verification technique to estimate the primary particle’s stopping power from prompt gamma timing measurements in proton therapy.Approach: The starting point is the Spatio-temporal Emission Recostruction technique, which provides the time-depth distribution of the emitted prompt photons with a multiple Prompt-Gamma Timing detector setup based on Lanthanum Bromide crystals. A dedicated formalism based on an analytical approximation of the stopping power is developed to obtain the desired information. Its performance is evaluated in a proof of concept configuration via Monte Carlo simulations of monochromatic proton beams impinging on a homogeneous PMMA phantom.Main Results: Results indicate stopping power estimations as good as 3.8% with respect to NIST values, and range estimations within 0.3 cm (standard deviation), when considering 250 ps FWHM timing resolution.Significance: The current study shows, for the first time, the feasibility of evaluating the stopping power of primary beams with a technique that can be performed in-vivo, opening up new possibilities in the field of treatment verification and therapy optimization.