BACKGROUND: Proton beam therapy using pencil beam scanning is an advanced radiotherapy technique that utilises proton beams to precisely target tumours. It is known for its enhanced ability in sparing healthy tissue and potentially reducing toxicity. Clinical experience with pencil beam scanning in the treatment of mediastinal Hodgkin lymphoma remains limited. PATIENTS AND METHODS: This study aimed to evaluate the toxicity and outcomes of a prospectively observed cohort. A total of 162 patients were irradiated between May 2013 and December 2020, with a median age of 32 years (range: 18.4-79.2) and followed up until April 2024. The median applied dose was 30 GyE (range: 20-40). Deep inspiration breath hold was used in 146 patients to enhance targeting precision. RESULTS: The disease-free survival, overall survival and local control rates were 95.1 %, 98.8 % and 98.8 %, respectively. The median follow-up was 59.1 months (range: 4-120.1). The most common acute toxicities observed were oesophageal and skin toxicity. Grade 1 oesophageal mucositis occurred in 76 patients (47 %), grade 2 in 16 patients (10 %). Dermatitis of grade 1 and 2 was observed in 65 (40 %) and 4 (3 %) patients respectively. Grade 1 pulmonary toxicity presented in 8 patients (4.9 %), and grade 2 in one patient (0.6 %). The most predominant late toxicity was grade 2 hypothyroidism in 37 patients (23 %). Three patients (1.8 %) underwent coronary interventions during follow-up, and one patient was diagnosed with hepatocellular carcinoma 3 months post-RT. No unexpected acute or late toxicities were observed. CONCLUSION: Proton beam therapy using pencil beam scanning is a safe and effective technique in terms of toxicity and local control, even when irradiating mediastinal targets.

Department of Hemato Oncology Faculty of Medicine and Dentistry Palacky University and University Hospital Olomouc Czech Republic

Department of Internal Medicine Hematology and Oncology University Hospital Brno Czech Republic; Faculty of Medicine Masaryk University Brno Czech Republic

General University Hospital in Praque 1st Medical Department Department of Heamatology Praha Czech Republic; Charles University 1st Faculty of Medicine Praha Czech Republic

Nuffield Department of Population Health University of Oxford Oxford UK; Department of Medical Physics and Clinical Engineering Guy's and St Thomas' NHS Foundation Trust London UK; School of Biomedical Engineering and Imaging Sciences King's College London London UK

Nuffield Department of Population Health University of Oxford Oxford UK; Oxford Cancer and Haematology Centre Oxford University Hospitals NHS Foundation Trust Churchill Hospital Oxford UK

Proton Therapy Center Czech Praha Czech Republic

Proton Therapy Center Czech Praha Czech Republic; Department of Health Care Disciplines and Population Protection Faculty of Biomedical Engineering Czech Technical University Prague Kladno Czech Republic

Proton Therapy Center Czech Praha Czech Republic; Institute of Nuclear and Molecular Medicine Banská Bystrica Slovakia

University Hospital Hradec Králové The 4th Department of Internal Medicine Hematology Hradec Králové Czech Republic

University Hospital Královské Vinohrady Department of Haematology and 3rd Faculty of Medicine Charles University Praha Czech Republic

University Hospital Ostrava and Faculty of Medicine University of Ostrava Department of Haematooncology Ostrava Czech Republic

University Hospital Pilsen Department of Haematology and Oncology Plzeň Czech Republic

Value Outcomes Praha Czech Republic

Value Outcomes Praha Czech Republic; Faculty of Mathematics and Physics Charles University Praha Czech Republic

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