A posteriori and predictive interplay evaluation methodology for lung and esophageal cancer patients treated in free breathing with IMPT

Abstract Objective. Pencil beam scanning proton therapy is sensitive to respiratory motion, leading to potential dose inhomogeneities due to interplay effects. We developed and validated a predictive framework to assess interplay and motion robustness in lung and esophageal cancer patients treated under free-breathing conditions. Approach. A synthetic-breathing-based predictive model was implemented in the RayStation treatment planning system and validated against an a posteriori approach using patient-specific respiratory traces and machine log files. Both were benchmarked against the Monte Carlo engine FRED. To demonstrate the methodology, the framework was applied to two clinical cases treated on the Mevion S250i system without rescanning. Dose accumulation incorporated respiratory phase, range ( ± 3%), and setup ( ± 5 mm) uncertainties. Main results. Excellent agreement was observed between TPS and FRED ( < 1% mean dose difference) and between predictive and a posteriori models ( < 2 % across DVH metrics). Cumulative dose distributions for the primary CTV converged after five fractions, confirming robust delivery. Significance. This automated, clinically integrated framework enables pre-treatment prediction and a posteriori validation of interplay and motion robustness in Pencil beam scanning plans. Preliminary results support its clinical utility, especially for hypofractionation and targets with large motion ( > 2 cm). A larger cohort study is ongoing and will be reported separately.