Assessment of a diaphragm override strategy for robustly optimized proton therapy planning for esophageal cancer patients

Sabine Visser*, Hendrike Neh, Cássia Oraboni Ribeiro, Erik W Korevaar, Arturs Meijers, Björn Poppe, Nanna M Sijtsema, Stefan Both, Johannes A Langendijk, Christina T Muijs, Antje C Knopf

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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PURPOSE: To ensure target coverage in the treatment of esophageal cancer, a density override to the region of diaphragm motion can be applied in the optimization process. Here, we evaluate the benefit of this approach during robust optimization for intensity modulated proton therapy (IMPT) planning.

MATERIALS AND METHODS: For ten esophageal cancer patients, two robustly optimized IMPT plans were created either using (WDO) or not using (NDO) a diaphragm density override of 1.05 g/cm3 during plan optimization. The override was applied to the excursion of the diaphragm between exhale and inhale. Initial robustness evaluation was performed for plan acceptance (setup errors of 8 mm, range errors of ±3%), and subsequently, on all weekly repeated 4DCTs (setup errors of 2 mm, range errors of ±3%). Target coverage and hotspots were analyzed on the resulting voxel-wise minimum (Vwmin ) and voxel-wise maximum (Vwmax ) dose distributions.

RESULTS: The nominal dose distributions were similar for both WDO and NDO plans. However, visual inspection of the Vwmax of the WDO plans showed hotspots behind the right diaphragm override region. For one patient, target coverage and hotspots improved by applying the diaphragm override. We found no differences in target coverage in the weekly evaluations between the two approaches.

CONCLUSION: The diaphragm override approach did not result in a clinical benefit in terms of planning and interfractional robustness. Therefore, we don't see added value in employing this approach as a default option during robust optimization for IMPT planning in esophageal cancer.

Original languageEnglish
Pages (from-to)5674-5683
Number of pages10
JournalMedical Physics
Issue number10
Early online date5-Aug-2021
Publication statusPublished - Oct-2021


  • 3D robust optimization
  • density override
  • diaphragm
  • esophageal cancer
  • intensity modulated proton therapy
  • 4D

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