Dosimetric comparison of scanned proton therapy and volumetric modulated arc therapy in isodose-prescribed stereotactic body radiotherapy for lung cancer

This study evaluated the feasibility of pencil beam scanning (PBS) proton therapy for stereotactic body radiotherapy using an isodose prescription in patients with isolated early-stage lung cancer, comparing dose-volume metrics with those of volumetric modulated arc therapy (VMAT). Treatment plans were generated for 10 patients with tumors located at least 2 cm from the trachea. Each plan prescribed 48 Gy(RBE) in four fractions with a 60% isodose prescription. Both multi-field optimized and single-field optimized PBS plans used four fields, while VMAT plans used two coplanar arcs. Plan robustness was assessed by simulating setup errors of ±5.0 mm and density uncertainties of ±3.5%, with worst-case target coverage also analyzed. Comparisons among the three planning strategies employed Bonferroni-adjusted multiple comparisons for target coverage, robustness, and organ-at-risk doses. PBS achieved target coverage comparable to VMAT, with similar D98% (63.2 ± 1.3 GyRBE vs. 64.0 ± 1.6 Gy; P = 0.12), mean doses (73.2 ± 0.8 GyRBE vs. 73.7 ± 1.2 Gy; P = 0.21), and robustness (D98%: 50.2 ± 0.9 GyRBE vs. 50.3 ± 1.1 Gy; P = 0.77). For the normal lung, PBS significantly reduced low-dose exposure up to V10Gy, whereas VMAT was more effective in reducing doses from V20Gy to the prescription level. All evaluated organ-at-risks received significantly lower mean doses with PBS than with VMAT (P < 0.05). Under a 60% isodose prescription for lung stereotactic body radiotherapy, multi-field optimized-based PBS proton therapy provides target coverage and robustness comparable to VMAT while offering superior normal tissue sparing.