This is a pilot study evaluating the feasibility of daily online adaptive planning for patients undergoing proton radiation therapy.

Patients undergoing proton radiation therapy normally undergo extensive pre-planning for their treatment. However, accounting for uncertainties in treatment delivery remains a challenge for a variety of reasons, such as differences in patient anatomy from pre-planning to the day of treatment. Online adaptive planning is a process consisting of generating the original pre-plan on the patient on a treatment day, assessing the pre-plan's coverage and safety, and if changes are needed, the plan is changed in order to optimize the treatment while the patient is still on the treatment table. This study is assessing the feasibility and safety of this approach in order to gather data for a larger trial.

Inclusion Criteria:

• Oligometastatic or primary malignancy planned for proton SBRT. Disease site should be biopsy-proven primary disease of solid tumor histology with the exception of Hepatocellular carcinoma (HCC). HCC does not need to be biopsy proven if imaging and clinical findings are consistent with the diagnosis.
• Must be deemed medically fit for proton SBRT by the treating physician.
• Prior radiation therapy is allowed.
• At least 18 years of age.
• Karnofsky ≥ 70%.
• Because radiation therapy is known to be teratogenic, women of childbearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control, abstinence) prior to study entry and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while participating in this study, or a male suspect he has fathered a child, s/he must inform the treating physician immediately.
• Ability to understand and willingness to sign an IRB approved written informed consent document.

Exclusion Criteria:

• Histology of small cell carcinoma. Mixed histologies with a predominantly small cell component are also exclusionary.
• Patients with a prior or concurrent malignancy whose natural history or treatment does not have the potential to interfere with the safety or efficacy assessment of the investigational regimen are eligible for this trial.
• Medical contraindication to proton therapy or any other condition that in the opinion of the treating radiation oncologist, renders the patient unfit for SBRT
• Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, or cardiac arrhythmia.
• Pregnant and/or breastfeeding. Women of childbearing potential must have a negative serum or urine pregnancy test within 14 days of study entry.

Individual participant data that underlie the results reported in this trial after de-identification. Other documents may be shared include the study protocol.

Beginning 9 months and ending 36 months after article publication.

Proposals to access study data should send request to amo@wustl.edu. To gain access, data requesters must sign data access agreement.

• Adverse events for patients were collected from start of treatment through 3 months post-end of SBRT. - All cause mortality was collected from the start of treatment through completion of follow-up 3 months post end of SBRT

All adverse events were collected with the exception of grade 1 AEs regardless of relatedness to treatment, and grade 2-4 AEs that are unlikely related or definitely not related to treatment. If the adverse event met the definition of a serious adverse event, it was collected regardless of attribution.