PMP

Progress in Medical Physics 29(4), December 2018

Original Article https://doi.org/10.14316/pmp.2018.29.4.157
eISSN 2508-4453

Dosimetric Evaluation of Plans Converted with the

DVH-Based Plan Converter
Minsoo Chun*,†,‡, Chang Heon Choi*,†,‡, Jung-in Kim*,†,‡, Jeongmin Yoon*,†,‡, Sung Young Lee*,†,
Ohyun Kwon*,†, Jaeman Son*,†, Hyun Joon An*,†, Seong-Hee KangΙΙ, Jong Min Park*,†,‡,§
*Department of Radiation Oncology, Seoul National University Hospital, †Biomedical Research Institute, Seoul National University
Hospital, ‡Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, §Center for Convergence
Research on Robotics, Advanced Institutes of Convergence Technology, Suwon, ΙΙDepartment of Radiation Oncology, Seoul
National University Bundang Hospital, Seongnam, Korea

Received 28 November 2018
Revised 14 December 2018
Accepted 14 December 2018
Corresponding author
Jong Min Park
(leodavinci@naver.com)
Tel: 82-2-2072-2527
Fax: 82-2-2072-2527
Plans converted using dose-volume-histogram-based plan conversion (DPC) were evaluated by
comparing them to the original plans. Changes in the dose volumetric (DV) parameters of five
volumetric modulated arc therapy (VMAT) plans for head and neck (HN) cancer and five VMAT
plans for prostate cancer were analyzed. For the HN plans, the homogeneity indices (HIs) of the
three planning target volumes (PTV) increased by 0.03, 0.02, and 0.03, respectively, after DPC.
The maximum doses to the PTVs increased by 1.20, 1.87, and 0.92 Gy, respectively, after DPC.
The maximum doses to the optic chiasm, optic nerves, spinal cord, brain stem, lenses, and parotid
glands increased after DPC by approximately 4.39, 3.62, 7.55, 7.96, 1.77, and 6.40 Gy,
respectively. For the prostate plans after DPC, the HIs for the primary and boost PTVs increased by
0.05 and 0.03, respectively, and the maximum doses to each PTV increased by 1.84 and 0.19 Gy,
respectively. After DPC, the mean doses to the rectum and femoral heads increased by
approximately 6.19 and 2.79 Gy, respectively, and those to the bladder decreased by 0.20 Gy when
summing the primary and boost plans. Because clinically unacceptable changes were sometimes
observed after DPC, plans converted by DPC should be carefully reviewed before actual patient
treatment.

Keywords: DVH-based plan converter, Volumetric modulated arc therapy, Step-and-shoot IMRT,
Dose-volumetric parameters, Plan quality

Introduction equivalent machine. The plan conversion types of the DPC

Dose-volume histogram (DVH) based plan converter be-
TM
came available in a new version of the Eclipse
planning system (ver. 13, Varian Medical System, Palo Alto,
CA). DVH-based plan conversion (DPC) can convert plans
in case of emergency such as a situation of the machine
break down. DPC can alter the original plan to one with
either an identical type machine or a non-dosimetrically
are as follows: volumetric modulated arc therapy (VMAT)
to step-and-shoot intensity-modulated radiation therapy
treatment (SS-IMRT), sliding window IMRT (SW-IMRT) to SS-IMRT,
and three-dimensional conformal radiation therapy (3D
CRT) to 3D CRT. To utilize the DPC function safely in the
clinic, the dosimetric equivalence between the original and
the converted plans should be verified, however, no studies
on this have been performed yet. Although a single study

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158 Minsoo Chun, et al：Dosimetric Evaluation on the Plans Converted with the DVH-based Plan Converter

introduced the DPC along with features of the new plan-
ning system, the function of the DPC was only briefly in-
1)
troduced. Therefore, in this study, we evaluated the DPC
by utilizing five head and neck, and five prostate cases.
Plan qualities before and after the DPC were dosimetrically
compared to each other.
Materials and Methods
1. Patient selection and treatment planning
A total of 10 patients previously treated in our institute
were analyzed in this study (five head and neck (HN) can-
cer patients and five prostate cancer patients). For every
patient, VMAT plans were generated in the Eclipse system
with an optimization algorithm of progressive resolution
optimizer 3 (PRO3, ver. 13.0, Varian Medical System, Palo
Alto, CA) and a dose calculation algorithm of anisotropic
analytical algorithm (AAA, ver. 13.0, Varian Medical Sys-
tem, Palo Alto, CA).
For HN cases, three target volumes were prescribed by
67.5 Gy (2.25 Gy/fraction), 54 Gy (1.8 Gy/fraction), and
48 Gy (1.6 Gy/fraction), respectively. The HN plans were
generated by using two full arcs with 6 MV photon beams
of the TrueBeam STxTM (Varian Medical System, Palo Alto,
CA).
In the prostate cases, the primary plan was generated
with a prescription dose of 50.4 Gy (1.8 Gy/fraction) to
prostate and seminal vesicles, and the boost plan was cre-
ated with a prescription dose of 30.6 Gy (1.8 Gy/fraction)
to prostate alone. Both the primary and boost plans were
generated by using two full arcs with 15 MV photon beams
of the TrilogyTM (Varian Medical System, Palo Alto, CA). All
the plans in this study were normalized for 100% of the pre-
scription doses to cover 90% of the planning target volume
(PTV).
2. DVH-based plan conversion
If the energy used in the original plan is not supported in
the target machine, the DPC automatically selects the en-
ergy of the converted plan closest to the one in the original
plan. In cases of SW-IMRT to SS-IMRT and 3D CRT to 3D
CRT conversion, the number of fields of the converted plan

Table 1. Treatment plan parameters before and after DPC.

Treatment sites Original plan Converted plan
Head and neck Na 5
Machine TrueBeam STx Trilogy
Energy 6 MV 6 MV
b
Treatment Technique VMAT SS-IMRTc
Input NFd - 8
Actual NF 2 14.8±2.2 (13~18)
Total MUe 581.9±181.0 (467.1~889.7) 730.4±60.9 (659.1~822.3)
MU/Gy 258.6±80.5 (207.6~395.4) 324.6±27.1 (293.0~365.5)
Beam-on time (minutes) 1.98±0.01 (1.98~2.00) 1.21±0.14 (1.1~1.5)
Prostate N 10 (Primary: 5, Boost: 5)
Machine Trilogy TrueBeam STx
Energy 15 MV 15 MV
Treatment Technique VMAT SS-IMRT
Input NFb - 8
Actual NF 2 8
Total MU 490.8±158.8 (365.5~886.2) 374.3±49.4 (326.6~470.5)
MU/Gy 272.6±88.2 (203.0~192.3) 208.0±27.4 (181.4~261.4)
Beam-on time (minutes) 2.49±0.03 (2.48~2.56) 0.63±0.08 (0.55~0.79)
a
N, number of patients; bVMAT, volumetric modulated arc therapy; cSS-IMRT, step-and-shoot intensity modulated radiation therapy; dNF,
number of fields; eMU, monitor unit.
Numerical values are presented by mean ± standard deviation, as well as minimum and maximum values are within parenthesis. 

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 Progress in Medical Physics Vol. 29, No. 4, December 2018 159

remains same as that of the original plan. However, in the
case of VMAT to SS-IMRT conversion, the number of fields
should be defined manually. In this study, we compared
the original VMAT plans and the SS-IMRT plans with eight
fields after applying the DPC. For fair comparison, the
number of fractions as well as daily doses of the converted
plans kept same with those of the original plan. The DPC
parameters in this study are summarized in Table 1.
(PTV67.5Gy), PTV54Gy, and PTV48Gy became slightly poor after
DPC (HI=0.05 vs. 0.08, 0.25 vs. 0.27, 0.11 vs. 0.14). Because
HN VMAT plans were optimized with the simultaneous
integrated boost (SIB) technique, the target conformity
was evaluated only for the PTV67.5Gy. The average CI of the
PTV67.5Gy was shown by 1.04 and 1.19 before and after DPC,
respectively.
For OARs, all the DV parameters after DPC were higher

3. Dose-volumetric parameter analysis

Table 2. The DV parameters before and after DPC for the HN
VMAT plans.
For the target volume, the dose received by at least 95%
Original Converted
of the PTV (D95%), D5%, the minimum dose (Dmin), and the plan plan
maximum dose (Dmax) were calculated. Additionally, the PTV67.5Gya
conformity index (CI), and homogeneity index (HI) were D5%b (Gy) 70.8±0.6 72.1±1.0
acquired as follows. D95% (Gy) 66.9±0.1 66.4±0.3
Dmaxc (Gy) 73.3±1.3 74.5±1.6
V100% of PTV Dmind (Gy) 52.0±11.8 55.2±61.7
Conformity intdex (CI)= (1) Dmeane (Gy) 69.0±0.3 69.7±0.5
Volume of PTV
CIf 1.04±0.08 1.19±0.14
HIg 0.05±0.01 0.08±0.02
D5%−D95% PTV54Gy
Homogeneity intdex (HI)= (2)
Mean dose of PTV D5% (Gy) 65.1±1.3 65.6±1.2
D95% (Gy) 53.6±0.2 53.5±1.0
where, V100% is the volume receiving 100% of the prescrip- Dmax (Gy) 70.8±0.8 72.7±1.2
tion dose. The DV parameters of the PTV were calculated Dmin (Gy) 31.6±5.2 35.9±3.7
for each target volume. Dmean (Gy) 57.4±0.6 58.1±0.9
For the HN VMAT plans, the Dmax values to the spinal HI 0.25±0.02 0.27±0.03
PTV48Gy
cord, brain stem, left/right lenses, left/right optic nerves,
D5% (Gy) 51.8±1.3 52.5±1.2
and optic chiasm were acquired. The mean doses (Dmean) D95% (Gy) 47.7±0.5 47.6±0.5
to the left/right parotid glands were also obtained.2,3) For Dmax (Gy) 57.4±2.9 58.4±3.6
the prostate VMAT plans, the DV parameters for the OARs Dmin (Gy) 39.1±3.7 41.5±2.9
Dmean (Gy) 49.7±0.6 50.0±0.7
were evaluated in the summation of primary and boost
HI 0.11±0.03 0.14±0.04
plans. The D60%, D20%, Dmean, and the percent volume receiv-
Organs at risk
ing 70 Gy (V70Gy) of the rectum; D50%, D20%, Dmean, and V70Gy of Dmax to optic chiasm (Gy) 16.5±18.4 20.9±19.5
the bladder; and Dmax, Dmean, D50%, and D10% of the femoral Dmax to left optic nerve (Gy) 14.9±13.2 19.3±16.1
heads were calculated.4-6) Dmax to right optic nerve (Gy) 14.6±13.0 17.4±13.3
Dmax to spinal cord (Gy) 42.5±2.1 50.0±6.0
Dmax to brain stem (Gy) 44.7±12.8 52.7±12.7
Results Dmax to left lens (Gy) 3.8±1.7 5.5±3.9
Dmax to right lens (Gy) 3.5±1.6 5.3±3.1
1. DPC for the HN plans Dmean to left parotid gland (Gy) 20.2±1.8 26.4±2.1
Dmean to right parotid gland (Gy) 21.0±7.8 27.6±10.7
a
The average DV parameters for the HN plans before and PTVnGy, planning target volume prescribed by n Gy; bDn%, dose
received by at least n% volume of a structure; cDmax, maximum
after DPC are shown in Table 2. The average target homo- dose; dDmin, minimum dose; eDmean, Mean dose; fCI, Conformity
geneities for the PTVs with a prescription dose of 67.5 Gy index; gHI, Homogeneity index.

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160 Minsoo Chun, et al：Dosimetric Evaluation on the Plans Converted with the DVH-based Plan Converter

than those before DPC. For an extreme case, the Dmax to the 2. DPC for the prostate plans
spinal cord and the brain stem were 45.99 Gy, and 55.56
Gy, respectively, which slightly exceeded the normal tissue The average DV parameters for the prostate plans before
tolerance guidance.7) A representative patient’s dose dis-
tributions before and after DPC are shown in Fig. 1. In this
case, low dose regions remarkably increased after DPC. 100 PTV67.5
PTV54
The DVHs of a representative HN case are presented in Fig. PTV48
80 Optic nerve (lt)
2, showing considerable increases in the doses to OARs,
Optic nerve (rt)
especially for optic chiasm, spinal cord, both lenses, and Optic chiasm

Volume (%)
60
Spinal cord
both parotid glands. Brain stem
The average monitor unit (MU) efficiency after DPC Lens (rt)
40
Lens (lt)
became poorer showing 32.0% higher MU/Gy compared Parotid gland (lt)
Parotid gland (rt)
to that of the original plan. The average beam-on times of 20

the converted plans decreased by 0.8 minutes although

it did not mean the reduction of the total treatment time
compared to that of original plan since the original plans
were VMAT plans which delivers prescription doses more
rapidly than did the SS-IMRT plans.
0
0 10 20 30 40 50 60 70 80
Dose (Gy)
Fig. 2. A representative patient’s dose volume histograms (DVHs)
for the head and neck case are shown. DVHs from the original
plan are plotted with solid lines, while those from the converted
plan using the dose volume histogram based plan conversion are
plotted with dashed lines.

a b c

d e f

Fig. 1. A representative patient’s dose distributions for the head and neck case are presented before (upper row) and after (lower row)
dose volume histogram based plan conversion. Doses are shown in color wash from 40% of the prescription dose to the maximum dose.
Axial (a and d), coronal (b and e), and sagittal (c and f ) planes are shown.

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 Progress in Medical Physics Vol. 29, No. 4, December 2018 161

and after DPC are shown in Table 3. The average target ho-
mogeneity after DPC became poor, showing higher values
of D5%, Dmax, and HI than those before DPC for both the
primary and boost PTVs. The plans after DPC showed bet-
ter target conformities than those before DPC for both the
primary and boost plans.
For OARs, all DV parameters of the converted plans be-
came poorer than those of the original plans except the
mean bladder doses. A representative patient’s dose distri-
butions and DVHs before and after DPC are shown in Fig.
3 and 4, respectively. Doses to rectum extremely increased
after DPC which can potentially induce acute and long-
term side effects.8,9)
The average MU efficiency after DPC improved show-
ing about 19.6% decreases in MU/Gy. The average beam-
on times decreased by 1.9 minutes after DPC although this
cannot guarantee the reduction of the total treatment time.

Table 3. The DV parameters before and after DPC for the prostate
VMAT plans. Note that the DV parameters for the OARs were Discussion
evaluated in the sum plan.
Original plan Converted plan The clinical appropriateness of the DPC was demonstrat-
Primary PTV a
ed in this study. Although DPC was intended to be used
D5%b (Gy) 52.2±0.2 54.2±1.0 only for a single or a small number of fractions in the case
D95% (Gy) 49.9±0.1 49.5±0.1 of emergency, the dosimetric equivalence should be vali-
Dmaxc (Gy) 53.9±0.6 55.8±1.3
dated before the clinical use. We found clinically relevant
Dmind (Gy) 40.0±10.2 42.7±1.3
Dmeane (Gy) 51.2±0.1 52.6±0.5 differences in the DV parameters for both HN and prostate
CIf 0.92±0.01 1.01±0.04 cases after DPC when the converted plans were delivered
HIg 0.04±0.01 0.09±0.02 during whole fractions. For the HN cases, although the DV
Boost PTV parameters of the PTVs were still clinically acceptable after
D5% (Gy) 31.7±0.1 32.3±0.5
DPC, those of OARs mostly exceeded the normal tissue
D95% (Gy) 30.3±0.0 30.1±0.1
Dmax (Gy) 32.5±0.2 32.7±0.5 constraints. For the prostate cases, all DV parameters after
Dmin (Gy) 27.8±0.4 27.2±0.6 DPC became poorer than those before DPC.
Dmean (Gy) 31.1±0.1 31.5±0.3 Although the user determined the number of fields when
CI 0.91±0.00 0.94±0.03 creating the converted plan, there are differences between
HI 0.04±0.00 0.07±0.02
the user input and the actual number of fields in HN cases.
Organs at risk
Rectum The relatively large target volumes cannot be fully covered
D60% (Gy) 32.1±2.3 42.0±4.7 with a single collimator position in the designated gantry
D20% (Gy) 63.4±2.0 66.4±1.8 angle, thereby the actual number of fields has increased
Dmean (Gy) 41.7±2.2 47.8±3.5
from the user input.
V70Gyh (cc) 11.0±6.3 12.1±7.3
One thing that should be checked when summing two
Bladder
D50% (Gy) 20.0±11.6 20.2±11.3 plans, i.e., sequential deliveries of the primary and boost
D20% (Gy) 49.2±9.6 49.4±10.4 plans, is that the gantry angles of the boost plan could be
Dmean (Gy) 28.8±9.4 28.6±9.1 overlapped with those of the primary plans, which is not
V70Gy (cc) 17.4±3.7 18.2±4.1
desirable in terms of spreading doses over a patient body to
Femur head
avoid irradiations of high or intermediate doses to normal
Dmax (Gy) 31.3±4.4 39.3±4.6
Dmean (Gy) 14.0±4.4 16.8±5.3 tissue. Although a single fraction in this study could influ-
D50% (Gy) 13.4±5.5 16.8±7.1 ence about 3.3% and 2.2% to the entire dose distribution
D10% (Gy) 21.9±3.2 27.6±3.7 for the HN (30 fractions) and the prostate (45 fractions)
a b
PTV, planning target volume; Dn%, dose received by at least n% plans, respectively, the final plan should be dosimetrically
volume of a structure; cDmax, maximum dose; dDmin, Minimum
dose; eDmean, mean dose; fCI, conformity index; gHI, homogeneity verified when applying the patient’s treatment.
index; hVnGy, the percent volume receiving n Gy. There exist several constraints in the use of DPC. When

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162 Minsoo Chun, et al：Dosimetric Evaluation on the Plans Converted with the DVH-based Plan Converter

a b c

d e f

Fig. 3. A representative patient’s dose distributions for the prostate case is presented before (upper row) and after (lower row) dose
volume histogram based plan conversion. Doses are shown in color wash from 30% of the prescription dose to the maximum dose. Axial
(a and d), coronal (b and e), and sagittal (c and f ) planes are shown.

100 PTV_primary is necessary to use DPC only for the small number of frac-
PTV_boost tions with careful review.
Rectum
80 Bladder
Femur head
Conclusion
Volume (%)

60

40 The converted plans with the DPC might show degraded

plan qualities compared to those of the original plans.
20 Therefore, when applying the DPC, careful review on the
converted plans is required.
0
0 10 20 30 40 50 60 70 80 90
Dose (Gy) Acknowledgements
Fig. 4. A representative patient’s dose volume histograms (DVHs)
for the prostate case are shown. DVHs from the original plan are This work was supported by the National Research
plotted with solid lines, while those from the converted plan using
Foundation of Korea (NRF) grant funded by the Korea
the dose volume histogram based plan conversion are plotted
with dashed lines. government (MSIP) (No.2017M2A2A7A02020641 and
2017M2A2A7A02020643).
the original plan is arranged with flattening filter free (FFF)
beams, selection of FFF beams in the converted plan is not Conflicts of Interest
available although the target machine has the FFF beam
mode. Furthermore, DPC does not support the plans cal- The authors have nothing to disclose.
®
culated with the Acuros XB advanced dose calculation
(Varian Medical Systems, Palo Alto, CA), allowing only Availability of Data and Materials
plans calculated with the AAA algorithm. Because there ex-
ist several limitations and clinically unacceptable changes All relevant data are within the paper and its Supporting
may occur in the dose distributions when applying DPC, it Information files.

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 Progress in Medical Physics Vol. 29, No. 4, December 2018
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