PTCOG Ocular Statement: Expert Summary of Current Practices and Future Developments in Ocular Proton Therapy.

Although rare cancers, ocular tumors are a threat to vision, quality of life, and potentially life expectancy of a patient. Ocular proton therapy (OPT) is a powerful tool for successfully treating this disease. The Particle Therapy Co-Operative Ocular Group (PTCOG Ocular) formulated an Evidence and Expert-Based Executive Summary of Current Practices and Future Developments in OPT: Comparative dosimetric and clinical analysis with the different OPT systems is essential to set up planning guidelines, implement best practices, and establish benchmarks for eye preservation, vision, and quality of life measures. Contemporary prospective trials in select subsets of patients (e.g., tumors near the optic disc and/or macula) may allow for dosimetric and clinical analysis between different radiation modalities and beamline systems to evaluate differences in radiation delivery and penumbra, and resultant tumor control, normal tissue complication rates, and overall clinical cost-effectiveness. To date, the combination of multimodal imaging (fundus photography, ultrasound, etc.), ophthalmologist assessment, and clip surgery with radiation planning have been keys to successful treatment. Increased use of 3D imaging (CT/MRI) is anticipated although its spatial resolution might be a limiting factor (e.g., detection of flat diffuse tumor parts). Commercially produced ocular treatment planning systems are under development and their future use is expected to expand across OPT centers. Future continuity of OPT will depend on (i) maintaining and upgrading existing older dedicated low-energy facilities, (ii) maintaining shared, degraded beamlines at large proton therapy centers, and (iii) developing adapted gantry beams of sufficient quality to maintain the clinical benefits of sharp beam conformity. Option (i) potentially offers the sharpest beams, minimizing impact on healthy tissues, whilst (ii) and (iii) potentially offer the advantage of substantial long-term technical support and development as well as the introduction of new approaches. Significant patient throughputs and close cooperation between medical physics, ophthalmology, and radiotherapy, underpinned by mutual understanding, is crucial for a successful OPT service.

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Declaration of competing interest The authors, except for Jan-Willem Beenaker (JWB), declare that they have no conflicts of interest regarding the publication of this manuscript. JWB receives research support from Philips Healthcare and RaySearch Laboratories and receives grant support from Varian Medical Systems.