Treatment planning comparison in the PROTECT-trial randomising proton versus photon beam therapy in oesophageal cancer: Results from eight European centres

Lone Hoffmann*, Hanna Mortensen, Muhammad Shamshad, Maaike Berbee, Nicola Bizzocchi, Rebecca Buetof, Richard Canters, Gilles Defraene, Mai Lykkegaard Ehmsen, Francesca Fiorini, Karin Haustermans, Ryan Hulley, Erik W. Korevaar, Matthew Clarke, Sebastian Makocki, Christina T. Muijs, Luke Murray, Owen Nicholas, Marianne Nordsmark, Ganesh RadhakrishnaMelissa Thomas, Esther G. C. Troost, Gloria Vilches-Freixas, Sabine Visser, Damien C. Weber, Ditte Sloth Moller

*Corresponding author for this work

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Purpose: To compare dose distributions and robustness in treatment plans from eight European centres in preparation for the European randomized phase-III PROTECT-trial investigating the effect of proton therapy (PT) versus photon therapy (XT) for oesophageal cancer.

Materials and methods: All centres optimized one PT and one XT nominal plan using delineated 4DCT scans for four patients receiving 50.4 Gy (RBE) in 28 fractions. Target volume receiving 95% of prescribed dose (V95%(iCTVtotal)) should be >99%. Robustness towards setup, range, and respiration was evaluated. The plans were recalculated on a surveillance 4DCT (sCT) acquired at fraction ten and robustness evaluation was performed to evaluate the effect of respiration and inter-fractional anatomical changes.

Results: All PT and XT plans complied with V95% (iCTVtotal) >99% for the nominal plan and V95% (iCTVtotal) >97% for all respiratory and robustness scenarios. Lung and heart dose varied considerably between centres for both modalities. The difference in mean lung dose and mean heart dose between each pair of XT and PT plans was in median [range] 4.8 Gy [1.1;7.6] and 8.4 Gy [1.9;24.5], respectively. Patients B and C showed large inter-fractional anatomical changes on sCT. For patient B, the minimum V95% (iCTVtotal) in the worst-case robustness scenario was 45% and 94% for XT and PT, respectively. For patient C, the minimum V95% (iCTVtotal) was 57% and 72% for XT and PT, respectively. Patient A and D showed minor inter-fractional changes and the minimum V95%(iCTVtotal) was >85%.

Conclusion: Large variability in dose to the lungs and heart was observed for both modalities. Inter-fractional anatomical changes led to larger target dose deterioration for XT than PT plans. (C) 2022 The Author(s). Published by Elsevier B.V.

Original languageEnglish
Pages (from-to)32-41
Number of pages10
JournalRadiotherapy and Oncology
Publication statusPublished - Jul-2022


  • Oesophageal cancer
  • Proton therapy
  • Intensity modulated radiotherapy
  • Treatment planning
  • Respiratory motion
  • Anatomical changes
  • Quality assurance
  • Phase III trial

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