Multi-centric study to harmonize LET-calculations in proton therapy

Purpose
Emerging clinical evidence for a varying relative biological effectiveness (RBE) in proton therapy poses the urgent need to consider RBE-driving physical parameters such as the linear energy transfer (LET). However, no harmonized concept exists on how to calculate the LET in clinical practice. Therefore, a multi-centric study was set up with the objective to standardize LET-calculations in Europe.

Materials and Methods
Eight European proton therapy institutions generated non-robust single-field-uniform-dose PBS treatment plans using common strict dose objectives. Multiple treatment field arrangements (single-field SOBP, perpendicular fields, opposing fields) were employed to cover a target cube in a water phantom. The institutions provided their dose and corresponding LET distributions. Here, four different LET-calculation methods (including analytical codes, dedicated LET scripts, Monte Carlo engines) were analyzed.

Results
Single-field SOBP ranges (distal R80) and average dose (range: D99 to D1) in the target volume agreed within 2% (Fig.1). In contrast, the corresponding near minimum LET values (LET99), average LET and near maximum LET (LET1) in the target volume differed up to 30%, 19% and 5%, respectively. In the volume 1 cm distal to the target, absolute (relative) LET1 values differed by up to 1.63 keV/µm (17%) in voxels with average physical dose above 40 Gy. Individual institutions included different ions in their LET-calculations partially explaining the observed differences in LET-values and LET-distributions (Fig.2).

Conclusion
Despite comparable dose distributions, substantial LET-differences occurred among the participating institutions. They hamper the consistent analyses of clinical follow-up data and might lead to discrepancies in predicting variable RBE. Therefore, standardized clinical LET-calculations are recommended.