Use of immobilizing individual abdominal corset in patients with upper-GI tumors treated with proton beam irradiation

Purpose/Objective: The irradiation of tumors, which are subject to respiration-induced motion is challenging for pencil beam scanning (PBS) based proton therapy due to the interplay effect and the temporally varying tissue densities along the beam path. Here, we report on the feasibility, tolerability and setup reproducibility of an individualized immobilization device for patients with tumors in the upper abdomen, who are treated with PBS.

Material/Methods: Since January 2018, nine patients with tumors in the upper abdomen (pancreas, liver and gall bladder) have been treated with PBS at our department. All patients eligible for this study underwent the following procedure within 10-days: (1) intra-tumoral implantation of three fiducial markers for target localization, (2) design of an individualized abdominal corset for motion reduction by abdominal compression, (3) abdominal MRI scan with intravenous contrast agent (c.a.) for target volume definition and tumor motion quantification, and (4) 4D-CT scan with c.a. for treatment planning. CT simulation and irradiation was performed with a vacuum mattress (Fig.1). Before each treatment fraction, the position of the target volume was verified with orthogonal X-ray imaging. First, a 2D/2D match with the DRRs was performed and then the position of the fiducial markers was verified (tolerance level: 3-5mm). In case this tolerance level was exceeded, a CT scan was performed in-room and the dose distribution was recalculated for plan comparison; in case of clinically relevant changes in the dose distribution, a new plan was calculated.

Result: All patients tolerated the marker implantation, the abdominal corset and the treatment well with no treatment interruptions. In 4 out of the 300 applied fractions (1,3%) the tolerance level of the fiducial markers was exceeded. For these fractions, the recalculated dose distribution nevertheless showed sufficient target coverage (Fig. 2). The entire treatment fraction (including patient positioning, setup verification and dose delivery) did not exceed the standard time slot of 30 minutes.

Conclusion: This study demonstrates that PBS-based proton therapy with an abdominal corset to reduce breathing motion of GI-tumors is feasible, well-tolerated by patients and provides a reproducible setup without prolonging the daily treatment time.