Objective: Next generation online and real-time adaptive radiotherapy workflows require precise particle transport simulations in sub-second times, which is unfeasible with current analytical pencil beam algorithms (PBA) or Monte Carlo (MC) methods. We present a deep learning based millisecond speed dose calculation algorithm (DoTA) accurately predicting the dose deposited by mono-energetic proton pencil beams for arbitrary energies and patient geometries. Approach: Given the forward-scattering nature of protons, we frame 3D particle transport as modeling a sequence of 2D geometries in the beam's eye view. DoTA combines convolutional neural networks extracting spatial features (e.g., tissue and density contrasts) with a transformer self-attention backbone that routes information between the sequence of geometry slices and a vector representing the beam's energy, and is trained to predict low noise MC simulations of proton beamlets using 80,000 different head and neck, lung, and prostate geometries. Main results: Predicting beamlet doses in 5±4.9 ms with a very high gamma pass rate of 99.37±1.17% (1%, 3 mm) compared to the ground truth MC calculations, DoTA significantly improves upon analytical pencil beam algorithms both in precision and speed. Offering MC accuracy 100 times faster than PBAs for pencil beams, our model calculates full treatment plan doses in 10-15 second depending on the number of beamlets (800-2200 in our plans), achieving a 99.70±0.14% (2%, 2 mm) gamma pass rate across 9 test patients. Significance: Outperforming all previous analytical pencil beam and deep learning based approaches, DoTA represents a new state of the art in data-driven dose calculation and can directly compete with the speed of even commercial GPU MC approaches. Providing the sub-second speed required for adaptive treatments, straightforward implementations could offer similar benefits to other steps of the radiotherapy workflow or other modalities such as helium or carbon treatments.

Particle physics simulations are the cornerstone of nuclear engineering applications. Among them radiotherapy (RT) is crucial for society, with 50% of cancer patients receiving radiation treatments. For the most precise targeting of tumors, next generation RT treatments aim for real-time correction during radiation delivery, necessitating particle transport algorithms that yield precise dose distributions in sub-second times even in highly heterogeneous patient geometries. This is infeasible with currently available, purely physics based simulations. In this study, we present a data-driven dose calculation algorithm predicting the dose deposited by mono-energetic proton beams for arbitrary energies and patient geometries. Our approach frames particle transport as sequence modeling, where convolutional layers extract important spatial features into tokens and the transformer self-attention mechanism routes information between such tokens in the sequence and a beam energy token. We train our network and evaluate prediction accuracy using computationally expensive but accurate Monte Carlo (MC) simulations, considered the gold standard in particle physics. Our proposed model is 33 times faster than current clinical analytic pencil beam algorithms, improving upon their accuracy in the most heterogeneous and challenging geometries. With a relative error of 0.34±0.2% and very high gamma pass rate of 99.59±0.7% (1%, 3 mm), it also greatly outperforms the only published similar data-driven proton dose algorithm, even at a finer grid resolution. Offering MC precision 4000 times faster, our model could overcome a major obstacle that has so far prohibited real-time adaptive proton treatments and significantly increase cancer treatment efficacy. Its potential to model physics interactions of other particles could also boost heavy ion treatment planning procedures limited by the speed of traditional methods.

Breathing interplay effects in Intensity Modulated Proton Therapy (IMPT) arise from the interaction between target motion and the scanning beam. Assessing the detrimental effect of interplay and the clinical robustness of several mitigation techniques requires statistical evaluation procedures that take into account the variability of breathing during dose delivery. In this study, we present such a statistical method to model intra-fraction respiratory motion based on breathing signals and assess clinical relevant aspects related to the practical evaluation of interplay in IMPT such as how to model irregular breathing, how small breathing changes affect the final dose distribution, and what is the statistical power (number of different scenarios) required for trustworthy quantification of interplay effects. First, two data-driven methodologies to generate artificial patient-specific breathing signals are compared: a simple sinusoidal model, and a precise probabilistic deep learning model generating very realistic samples of patient breathing. Second, we investigate the highly fluctuating relationship between interplay doses and breathing parameters, showing that small changes in breathing period result in large local variations in the dose. Our results indicate that using a limited number of samples to calculate interplay statistics introduces a bigger error than using simple sinusoidal models based on patient parameters or disregarding breathing hysteresis during the evaluation. We illustrate the power of the presented statistical method by analyzing interplay robustness of 4DCT and Internal Target Volume (ITV) treatment plans for a 8 lung cancer patients, showing that, unlike 4DCT plans, even 33 fraction ITV plans systematically fail to fulfill robustness requirements.

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Background: Fast dose calculation is critical for online and real-time adaptive therapy workflows. While modern physics-based dose algorithms must compromise accuracy to achieve low computation times, deep learning models can potentially perform dose prediction tasks with both high fidelity and speed. Purpose: We present a deep learning algorithm that, exploiting synergies between transformer and convolutional layers, accurately predicts broad photon beam dose distributions in few milliseconds. Methods: The proposed improved Dose Transformer Algorithm (iDoTA) maps arbitrary patient geometries and beam information (in the form of a 3D projected shape resulting from a simple ray tracing calculation) to their corresponding 3D dose distribution. Treating the 3D CT input and dose output volumes as a sequence of 2D slices along the direction of the photon beam, iDoTA solves the dose prediction task as sequence modeling. The proposed model combines a Transformer backbone routing long-range information between all elements in the sequence, with a series of 3D convolutions extracting local features of the data. We train iDoTA on a dataset of 1700 beam dose distributions, using 11 clinical volumetric modulated arc therapy (VMAT) plans (from prostate, lung, and head and neck cancer patients with 194-354 beams per plan) to assess its accuracy and speed. Results: iDoTA predicts individual photon beams in ≈ 50 ms with a high gamma pass rate of 97.72 ± 1.93% (2 mm, 2%). Furthermore, estimating full VMAT dose distributions in 6-12 s, iDoTA achieves state-of -the-art performance with a 99.51 ± 0.66% (2 mm, 2%) pass rate and an average relative dose error of 0.75 ± 0.36%. Conclusions: Offering the millisecond speed prediction per beam angle needed in online and real-time adaptive treatments, iDoTA represents a new state of the art in data-driven photon dose calculation. The proposed model can massively speed-up current photon workflows, reducing calculation times from few minutes to just a few seconds.