Detailed evaluation of an automated approach to interactive optimization for volumetric modulated arc therapy plans

Purpose: Interactive optimization during treatment planning requires intermittent adjustment of organ-at-risk (OAR) objectives relative to the dose-volume histogram line. This is a labor-intensive process and the resulting plans are prone to variations in quality. The authors in-house developed approach to automated interactive optimization (AIO) automatically moves the mouse cursor to adjust the position of on-screen optimization objectives. This allows for the use of more objectives per OAR and results in a more frequent and consistent adjustment of these objectives during optimization. The authors report a detailed evaluation of AIO performance in support of its implementation for routine head and neck cancer (HNC) planning and an evaluation for locally advanced lung cancer (LC) planning which requires a different optimization strategy. Methods: Volumetric modulated arc therapy AIO plans (APs) were created for 70 HNC patients with a simultaneously integrated boost and 20 LC patients and benchmarked against their respective manually interactively optimized plans (MPs). The same set of optimization objectives and priorities was used for all APs, although planning target volume (PTV) optimization priorities could be increased manually in a subsequent continue previous optimization calculation. HNC plans were benchmarked using mean dose to individual and composite OARs and elective/boost PTV (PTV_E/PTV_B) volumes receiving 95% and 107% of the prescription dose (V95% and V107%, respectively). A clinician performed blinded comparison of 20 APs and respective MPs. LC plans were compared using PTV V95%/V107%, contralateral lung (CL) volume receiving 5 Gy (V5Gy), total lung (TL)-PTV V5Gy/V20Gy, and esophagus and heart V40Gy/V60Gy/mean doses. Results: For HNC, statistically significant improvements in sparing of all OARs, except for the ipsilateral submandibular gland and trachea, were obtained in the APs compared to MPs. Average mean dose to oral cavity, composite salivary, and swallowing structures were 25.4/23.8, 24.2/23.2, and 29.5/25.5 Gy, respectively, for the MPs/APs. PTV heterogeneity was similar: in the APs, PTV_B V95% was 0.2% higher while PTV_B/PTV_E V107% was 0.4%/1.0% lower. In 19 out of 20 HNC patients, the clinician preferred the AP, mainly because of better OAR sparing and PTV dose homogeneity. For LC, APs had a significantly lower CL V5Gy (6.1%), heart mean dose/V60Gy (0.9 Gy/1.2%) and esophagus mean dose/V60Gy (0.9 Gy/2.8%), a nonsignificantly higher TL V20Gy (1.4%), and a slight, but significantly higher dose deposition to the body. PTV dose coverage and homogeneitywere similar in the APs and MPs. AIO was considered sufficiently robust for clinical use in LC. Conclusions: HNC and LC APs were at least as good as, and often of improved quality over MPs. To date, AIO has been clinically implemented for HNC planning.