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The purpose of this study was to evaluate whether a spacer inserted in the prerectal space could reduce modeled rectal dose and toxicity rates for patients with prostate cancer treated in silico with pencil beam scanning (PBS) proton therapy. A total of 20 patients were included in this study who received photon therapy (12 with rectal spacer (DuraSeal™ gel) and 8 without). Two PBS treatment plans were retrospectively created for each patient using the following beam arrangements: (1) lateral‐opposed (LAT) fields and (2) left and right anterior oblique (LAO/RAO) fields. Dose volume histograms (DVH) were generated for the prostate, rectum, bladder, and right and left femoral heads. The normal tissue complication probability (NTCP) for ≥grade 2 rectal toxicity was calculated using the Lyman–Kutcher–Burman model and compared between patients with and without the rectal spacer. A significantly lower mean rectal DVH was achieved in patients with rectal spacer compared to those without. For LAT plans, the mean rectal V70 with and without rectal spacer was 4.19 and 13.5%, respectively. For LAO/RAO plans, the mean rectal V70 with and without rectal spacer was 5.07 and 13.5%, respectively. No significant differences were found in any rectal dosimetric parameters between the LAT and the LAO/RAO plans generated with the rectal spacers. We found that ≥ 9 mm space resulted in a significant decrease in NTCP modeled for ≥grade 2 rectal toxicity. Rectal spacers can significantly decrease modeled rectal dose and predicted ≥grade 2 rectal toxicity in prostate cancer patients treated in silico with PBS. A minimum of 9 mm separation between the prostate and anterior rectal wall yields the largest benefit.

The purpose of this work was to develop a method to calculate and study the impact of fluctuations in the magnetic field strengths within the steering magnets in a proton scanning beam treatment nozzle on the dose delivered to the patient during a proton therapy treatment. First, an analytical relationship between magnetic field uncertainties in the steering magnets and the resulting lateral displacements in the position of the delivered scanned beam "dose spot" was established. Next, using a simple 3D dose calculation code and data from a validated Monte Carlo model of the proton scanning beam treatment nozzle, the uniform dose delivery to a 3D treatment volume was calculated. The dose distribution was then recalculated using the calculated lateral displacements due to magnetic field fluctuations to the proton pencil beam position. Using these two calculated dose distributions, the clinical effects of the magnetic field fluctuations were determined. A deliberate displacement of four adjacent spots either toward or away from each other was used to determine the "maximum" dose impact, while a random displacement of all spots was used to establish a more realistic clinical dose impact. Changes in the dose volume histogram (DVH) and the presence of hot and cold spots in the treatment volume were used to quantify the impact of dose-spot displacement. A general analytical relationship between magnetic field uncertainty and final dose-spot position is presented. This analytical relationship was developed such that it can be applied to study magnetic beam steering for any scanned beam nozzle design. Using this relationship the authors found for the example beam steering nozzle used in this study that deliberate lateral displacements of 0.5 mm or random lateral displacements of up to 1.0 mm produced a noticeable dose impact (5% hot spot) in the treatment volume. A noticeable impact (3% decrease in treatment volume coverage) on the DVH was observed for random displacements of up to 1.5 mm. For the scanning nozzle studied in this work, these displacement values correlated with an uncertainty value of 2.04% in the magnetic field values of the nozzle steering magnets. The authors conclude that fluctuations in the dose-spot delivery caused by uncertainty in the magnet fields used for beam steering could have clinically significant effects on the delivered dose distribution. Due to differences in the design and implementation of proton beam scanning nozzles at different treatment facilities, the effects of magnetic field fluctuations of dose delivery should be evaluated and understood for each specific nozzle design during clinical commissioning of the treatment nozzle.