Initial Report of Pencil Beam Scanning Proton Therapy for Posthysterectomy Patients With Gynecologic Cancer

Int J Radiat Oncol Biol Phys. 2016 May 1;95(1):181-189. doi: 10.1016/j.ijrobp.2015.07.2205. Epub 2015 Jul 11.


Purpose: To report the acute toxicities associated with pencil beam scanning proton beam radiation therapy (PBS) for whole pelvis radiation therapy in women with gynecologic cancers and the results of a dosimetric comparison of PBS versus intensity modulated radiation therapy (IMRT) plans.

Methods and materials: Eleven patients with posthysterectomy gynecologic cancer received PBS to the whole pelvis. The patients received a dose of 45 to 50.4 Gy relative biological effectiveness (RBE) in 1.8 Gy (RBE) daily fractions. Acute toxicity was scored according to the Common Terminology Criteria for Adverse Events, version 4. A dosimetric comparison between a 2-field posterior oblique beam PBS and an IMRT plan was conducted. The Wilcoxon signed rank test was used to assess the potential dosimetric differences between the 2 plans and PBS target coverage robustness relative to setup uncertainties.

Results: The median patient age was 55 years (range 23-76). The primary site was cervical in 7, vaginal in 1, and endometrial in 3. Of the 11 patients, 7 received concurrent cisplatin, 1 each received sandwich carboplatin and paclitaxel chemotherapy, both sandwich and concurrent chemotherapy, and concurrent and adjuvant chemotherapy, and 1 received no chemotherapy. All patients completed treatment. Of the 9 patients who received concurrent chemotherapy, the rate of grade 2 and 3 hematologic toxicities was 33% and 11%, respectively. One patient (9%) developed grade 3 acute gastrointestinal toxicity; no patient developed grade ≥3 genitourinary toxicity. The volume of pelvic bone marrow, bladder, and small bowel receiving 10 to 30 Gy was significantly lower with PBS than with intensity modulated radiation therapy (P<.001). The target coverage for all PBS plans was robust relative to the setup uncertainties (P>.05) with the clinical target volume mean dose percentage received by 95% and 98% of the target volume coverage changes within 2% for the individual plans.

Conclusions: Our results have demonstrated the clinical feasibility of PBS and the dosimetric advantages, especially for the low-dose sparing of normal tissues in the pelvis with the target robustness maintained relative to the setup uncertainties. Future studies with larger patient numbers are planned to further validate our preliminary findings.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Aged
  • Antineoplastic Agents / therapeutic use
  • Endometrial Neoplasms / diagnostic imaging
  • Endometrial Neoplasms / radiotherapy*
  • Endometrial Neoplasms / surgery
  • Feasibility Studies
  • Female
  • Humans
  • Hysterectomy
  • Intestine, Small / radiation effects
  • Lymphatic Irradiation / methods
  • Middle Aged
  • Organ Sparing Treatments / adverse effects
  • Organ Sparing Treatments / methods
  • Organs at Risk / radiation effects
  • Pelvic Bones / radiation effects
  • Pelvis
  • Postoperative Period
  • Prospective Studies
  • Proton Therapy / adverse effects
  • Proton Therapy / methods*
  • Radiography
  • Radiotherapy Dosage
  • Radiotherapy Planning, Computer-Assisted / adverse effects
  • Radiotherapy Planning, Computer-Assisted / methods*
  • Radiotherapy, Intensity-Modulated / adverse effects
  • Radiotherapy, Intensity-Modulated / methods*
  • Re-Irradiation / statistics & numerical data
  • Relative Biological Effectiveness
  • Urinary Bladder / radiation effects
  • Uterine Cervical Neoplasms / radiotherapy*
  • Uterine Cervical Neoplasms / surgery
  • Vaginal Neoplasms / diagnostic imaging
  • Vaginal Neoplasms / radiotherapy*
  • Vaginal Neoplasms / surgery


  • Antineoplastic Agents