Cumulative Dose Analysis in Adaptive Carbon Ion Radiotherapy for Locally Advanced Non-Small Cell Lung Cancer

<b>Objectives</b>: This study aimed to assess the precision of dose delivery to the target in adaptive carbon ion radiotherapy (CIRT) for locally advanced non-small cell lung cancer (LA-NSCLC) in cumulative dosimetry. <b>Methods:</b> Forty-six patients who received CIRT were included (64 Gy[relative biological effectiveness, RBE] in 16 fractions) with treatment plan computed tomography (CT) and weekly CT scans. Offline adaptive radiotherapy (ART) was administered if the dose distribution significantly worsened. Daily doses were calculated from weekly CTs and integrated into plan CT scans using deformable image registration. The dosimetry parameters were compared between the as-scheduled plan and adaptive replan in patients receiving ART. Survival outcomes and toxicity were compared between the ART and non-ART groups. <b>Results:</b> ART was implemented for 27 patients in whom adaptive replans significantly increased the median V_98% of the clinical tumor volume from 96.5% to 98.1% and D_98% from 60.5 to 62.7 Gy(RBE) compared with the as-scheduled plans (<i>p</i> < 0.001). The conformity and uniformity of the dose distribution improved (<i>p</i> < 0.001), with no significant differences in the doses to normal tissues (lungs, heart, esophagus, and spinal cord) from the as-scheduled plans (<i>p</i> > 0.05). The ART and non-ART groups demonstrated comparable local control, progression-free survival, and overall survival (<i>p</i> > 0.05). No grade 3 or higher radiation-related toxicities were observed. <b>Conclusions:</b> ART enhanced target dose coverage while maintaining acceptable normal tissue exposure, supporting weekly CT monitoring integration during CIRT for the timely intervention for anatomical variations, ensuring precise dose delivery in LA-NSCLC.