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Intensity-modulated proton therapy decreases dose to organs at risk in low-grade glioma patients: results of a multicentric in silico ROCOCO trial

Eekers, D.; Roelofs, E.; Cubillos-Mesias, M.; Niel, C.; Smeenk, R.; Minken, A.; Granzier, M.; Janssens, G.; Kaanders, J.; Lambin, P.; Troost, E. G. C.


Background and Purpose
Patients with low-grade glioma (LGG) have a prolonged survival expectancy due to better discriminative tumor classification and multimodal treatment. Consequently, longterm treatment toxicity, e.g., neurocognitive function, gains importance. Contemporary radiotherapy techniques such as intensity-modulated radiotherapy (IMRT), volumetric modulated arc therapy (VMAT), Tomotherapy (TOMO) and intensity-modulated proton therapy (IMPT) enable high-dose irradiation of the target but they differ regarding delivered dose to organs at risk (OARs). The aim of this comparative in silico study was to determine the dosimetric differences in delivered doses to the OARs.
Material and Methods
Imaging datasets of twenty-five LGG patients having undergone postoperative radiotherapy were included. For each of these patients, in silico treatment plans to a total dose of 50.4Gy to the target volume were generated for the four treatment modalities investigated (i.e., IMRT, VMAT, TOMO, IMPT). Resulting treatment plans were analyzed regarding dose to target and surrounding OARs comparing IMRT, TOMO and IMPT to VMAT (reference technique).
In total, 100 treatment plans for the twenty-five patients were analyzed. Compared to VMAT the IMPT mean dose (Dmean) for 9 out of 10 (90%) OARs was statistically significantly (p<0.02) reduced, for TOMO 3/10 (30%) and 1/10 (10%) for IMRT. IMPT was the prime modality reducing dose to the OARs followed by TOMO. The pituitary gland was best spared by TOMO (Table 2).
The low dose volume to the majority of OARs was significantly reduced when using IMPT compared to VMAT. Whether this will lead to a significant reduction in neurocognitive decline is to be determined in carefully designed future clinical trials.

Keywords: In silico planning study; Low Grade Glioma; Photon and proton irradiation; IMPT; VMAT; IMRT; TOMO


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