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Medical Dosimetry xxx (xxxx) xxx

Medical Dosimetry
journal homepage: www.meddos.org

Impact of treatment planning quality assurance software on

volumetric-modulated arc therapy plans for prostate cancer patients
Motoharu Sasaki, PhD a,∗, Yuji Nakaguchi, PhD b, Takeshi Kamomae, PhD c, Akimi Kajino, BS d,
Hitoshi Ikushima, MD, PhD a
a
Department of Therapeutic Radiology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima 770-8503, Japan
b
Toyo Medic Co. Ltd, Shinjyukuku, Tokyo 162-0813, Japan
c
Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
d
School of Health Sciences, Tokushima University, Tokushima 770-8503, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Software that evaluates the quality of treatment plans (PlanIQTM ) has become commercially
Received 16 January 2021
available in recent years. It includes a feasibility assessment tool that provides the ideal dose volume
Revised 24 March 2021
histogram (DVH) for each organ at risk, based on the ideal dose falloff from the prescribed dose at the
Accepted 25 March 2021
Available online xxx target boundary. It is important to investigate whether the PlanIQTM assessment tool (Feasibility DVHTM )
can assist treatment planners who have limited to no experience in treatment planning. Therefore, the
Keywords: present study aimed to evaluate this tool’s usefulness for improving the quality of treatment plans.
Dosimetry Materials & Methods: This study included 5 patients with prostate cancer. The treatment planners were
Treatment planning quality 2 graduate students, 2 undergraduate students, and one clinical planner. All students were radiological
PlanIQ
technology and medical physics students with no clinical experience. Two different volumetric-modulated
Dose volume histogram
arc therapy (VMAT) plans were developed before and after Feasibility DVHTM . The quality of each treat-
Prostate cancer
ment plan was evaluated based on a scoring system implemented in PlanIQTM .
Results: Of 5 patients included, 4 received improved treatment plans when Feasibility DVHTM was used.
Moreover, 4 of 5 treatment planners showed improvement in treatment planning using Feasibility DVHTM .
Conclusions: The findings suggest that using the Feasibility DVHTM tool may improve treatment plans for
different planners and patients. However, planners at any level of experience should be trained to check
the dose distribution in addition to checking the DVH, which depends on the adequacy of the contours.
© 2021 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.

Introduction
Recently, intensity-modulated radiation therapy (IMRT) and
volumetric-modulated arc therapy (VMAT), which are associated
with better physical dose distribution than that associated with 3-
dimensional conformal radiation therapy, have gained popularity.
High-precision radiotherapy, such as IMRT and VMAT, reduces the
dose to organs at risk (OAR) while helping achieve the maximum
target dose.1 ,2 Both IMRT and VMAT routinely use dose constraint
sheets to guide treatment planning specific to each hospital. Dose
constraints tend to be hospital-specific, and each institution should
set its guidance on evidence from clinical studies. However, dose
constraint sheets do not provide information about the treatment
∗
Reprint requests to: Department of Therapeutic Radiology, Institute of Biomed-
ical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho,
Tokushima, Tokushima 770-8503, Japan.
E-mail address: msasaki@tokushima-u.ac.jp (M. Sasaki).
plan that could be achieved for a particular patient; instead, they
are recommendations on OAR dose limitations.3-5 Therefore, satis-
fying the criterion of a dose constraint sheet alone is insufficient
for assessing whether a particular treatment plan is optimal.
Typically, the radiation oncologist, via the dose prescription, in-
structs the treatment planner who provides an optimal treatment
plan. The treatment planner provides the target dose and OAR con-
straints as input data to the optimizer, which is programmed to
identify the minimum cost function that incorporates the target
dose and OAR dose limits required for the given treatment plan.6 ,7
The resulting treatment plan submitted by the planner to the ra-
diation oncologist is the most suitable of several options. However,
assessing such a plan’s suitability is challenging, making the plan-
ner’s task complex, while the recommended plan directly impacts
clinical outcomes. This process though is driven by the preplanning
instructions and prescription given to the treatment planner by the
radiation oncologist.

https://doi.org/10.1016/j.meddos.2021.03.013
0958-3947/© 2021 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.
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Table 1 Table 2
Patient characteristics. Dose volume constraints used in treatment planning.

Structure Case1 Case2 Case3 Case4 Case5 Structure Constraint

CTV 36.8 49.5 34.5 95.2 43.2 CTV V100% ≥ 99.5%

PTV excluding rectum 120.7 128.7 110.2 211.7 125.4 PTV excluding rectum D95% = 78 Gy
Overlap 5.2 4.5 5.8 4.4 5.1 Rectum V40 Gy ≤ 50%
Rectum 26.4 29.1 65.7 36.3 60.1 V60 Gy ≤ 25%
Bladder 196.5 172.4 85.8 432.5 61.2 V70 Gy ≤ 15%
(cc) V75 Gy ≤ 5%
Bladder V40 Gy ≤ 50%
All structure volumes are in units of cubic centimeters (cc). V65 Gy ≤ 25%
CTV, clinical target volume; PTV, planning target volume.
CTV, clinical target volume; PTV, planning target volume.

Table 3
PlanIQTM software (Sun Nuclear, Melbourne, Florida, USA) has The PQM scoring table.
been marketed as a tool for the objective assessment of treatment
Structure Metric Minimum Maximum
plan quality. Previously, the PlanIQTM software was used to com-
pare the pros and cons of multiple treatment plans.8-10 This soft- Criteria Score Criteria Score
ware includes a feasibility assessment tool that provides the ideal CTV V100% (%) 99.1 (%) 0 100 (%) 20
dose volume histogram (DVH) for each organ at risk, based on the PTV excluding rectum D98% (Gy) 75.8 (Gy) 0 77.3 (Gy) 25
ideal dose fall-off from the prescribed dose at the target boundary. D2% (Gy) 84.9 (Gy) 0 81.9 (Gy) 25
Rectum V40 Gy (%) 42.9 (%) 0 28.0 (%) 20
Treatment plan evaluations made before and after referencing the V60 Gy (%) 21.9 (%) 0 13.1 (%) 30
Feasibility DVHTM tool have shown that its use can improve treat- V70 Gy (%) 11.9 (%) 0 5.7 (%) 30
ment plan quality.11-13 V75 Gy (%) 5.4 (%) 0 1.2 (%) 30
Previous studies involved objective clinical planning assess- Bladder V40 Gy (%) 47.8 (%) 0 17.6 (%) 10
V65 Gy (%) 25.0 (%) 0 5.3 (%) 10
ments8-10 using PlanIQTM software and treatment plan improve-
ments using the Feasibility DVHTM tool.11-13 To date, no study has CTV, clinical target volume; PTV, planning target volume; PQM, plan quality metric.
investigated the percentage of improvement in treatment plan-
ning before and after referencing the Feasibility DVHTM among stu-
dents with no treatment plan preparation experience. Dosimetrists Students’ treatment plans

and treatment planners could replace individuals without rele-

vant training and those that rely on software to develop treatment
plans. Although software may assist in treatment planning, it does
not replace the training required to use it properly. Nevertheless,
if a student with no experience in treatment planning can plan a
treatment independently using Feasibility DVHTM , it may serve as
evidence of the proof-of-concept of Feasibility DVHTM utility.
The present study involved four students with no clinical expe-
rience, attending radiological technology or medical physics train-
ing schools. Two of them were fourth-year undergraduates and had
obtained classroom credits in radiotherapy equipment, radiother-
apy technology, and radiation oncology but had no practical expe-
rience in clinical settings, including hospital practice. Two students
enrolled in a master’s course had already obtained a medical radio-
grapher certificate and were studying for a medical physicist’s cer-
tificate at the time of the present study. These students had both
theoretical and practical knowledge of radiation therapy. This study
aimed to evaluate the impact of using the Feasibility DVHTM tool
Each student individually implemented a VMAT plan based on the dose con-
straint sheet. The training included information on the clinical contouring proto-
col; dose constraint tolerance; and dose, volume, and priority settings in TPS op-
timization. Ahead of enrollment, the participating students were provided at least
3 months of training on dynamic-IMRT and VMAT planning for prostate, and head
and neck cancer, and multiple brain metastasis cases. Knowledge on implementing
practice plans and performing prostate VMAT were considered equivalent to under-
standing the concepts of dose constraints and treatment planning.
The study participants were two undergraduate students (Students A and B) in
their fourth year of study and two graduate students (Students C and D) in their
second year of a master’s program. All of them were radiological technology and
medical physics students with no clinical experience. Two undergraduate students
were recruited from 37 fourth-year students. In addition, 2 graduate students were
recruited from 10 second-year graduate students. The students’ treatment plans
matched the clinical plans in terms of energy, JAW opening, arc number, and the
angle of the isocenter, while they differed in optimization settings. To help stu-
dents implement the treatment plan, we provided them with our institution’s dose
constraint sheet (Table 2). Informed consent was obtained from all participants. All
procedures were performed in accordance with the ethical standards of the institu-
tional and/or national research committee and the 1964 Declaration of Helsinki and
the subsequent amendments or equivalent ethical standards.

on VMAT treatment plans for prostate cancer patients developed

by the participating students. Using Feasibility DVHTM

Materials and Methods
This study included five patients who underwent VMAT for prostate cancer at
our institution. The cases included in this study were selected from those that un-
derwent treatment planning between 2012 and 2019, with no volume bias in the
clinical target volume (CTV), rectum, or bladder. A radiation oncologist reviewed
each patient’s contour/volume to ensure that it was appropriate. The contours of
the OAR were also predefined for the purpose of this study. The linear accelera-
tor used was TrueBeam (Varian Medical Systems, Palo Alto, CA, USA) with 10MV-
X of energy. The treatment planning system (TPS) was Eclipse (Varian Medical
Systems, Palo Alto, CA, USA), version 11.0.31. The dose was calculated using an
anisotropic analytical algorithm. VMAT was performed in 2Arc in clockwise and
counter-clockwise directions from 181° to 179° and 179° to 181°, respectively. All
treatment plans used a dose calculation grid measuring 2.5 × 2.5 × 2.5 mm. The
contour information used for treatment planning was the CTV, based on the plan-
ning target volume (PTV) excluding the rectum and bladder. Our institution’s pre-
scribed dose is 78 Gy in 39 fractions, defined as a dose that includes 95% of the
PTV excluding the rectum (D95%). Case details are presented in Table 1.
After referring to the Feasibility DVHTM tool, only the optimization settings were
changed in the treatment plan. Therefore, the settings of isocenter, energy, JAW
opening, and the number and angle of arcs were the same in the treatment plan
before and after referring to the Feasibility DVHTM tool.
Quality assessment of the treatment plan
The quality of each treatment plan was assessed using a scoring system known
as the plan quality metric (PQM), which has been proposed by Nelms et al. and
implemented in the PlanIQTM software.8 The relative importance of each item was
defined using a score within the target dose and OAR dose limits. Scoring the entire
treatment plan based on prioritization criteria can facilitate a treatment plan assess-
ment and serve as a benchmark for continuous improvement. The PQM scores used
in this study are shown in Table 3. A team of four professional planners determined
the relative values of the PQM scores, which were subsequently reviewed and ap-
proved by radiation oncologists. There was no ambiguity regarding the importance
of each relative PQM score, as each of them reflected the aims and objectives of a
particular treatment plan. The PQM scores used in this study involved nine com-
ponents. Each component was scored based on metric and submetric parameters.
These components were created based on three target coverage and six OAR dose
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Fig. 1. Comparison of PQM scores per case before (a) and after (b) referring to the Feasibility DVHTM tool. PQM: Plan Quality Metric.

Fig. 2. Dose distribution and dose volume histogram for student B with Case 4 average treatment plan with lower average PQM score before (a) and after (b) referring to
the Feasibility DVHTM tool. PQM: Plan Quality Metric.

limit values. The values between the maximum and minimum scores of the nine
subcomponents were obtained through linear interpolation.
Results
Differences among cases
The treatment plans for five prostate cancer cases resulted from each plan-
ner’s implementation of the treatment plan. Differences between the PQM scores
per case before and after referring to the Feasibility DVHTM tool are presented in
Fig. 1. The treatment plans for the target cases were created before referring to Fea-
sibility DVHTM ; Case 3 had the lowest average PQM score; Case 4 had the highest.
In treatment plan comparisons, after referring to Feasibility DVHTM , the mean PQM
score improved in 4 of 5 cases, with the most significant improvement in treatment
plan quality observed in Case 3. In addition, the variation in PQM scores decreased
for Cases 2 and 5. Fig. 2 shows the dose distribution and DVH of student B, who
provided an average treatment plan based on the PQM score for Case 4, where the
average PQM score after referring to Feasibility DVHTM was lower than that before
referring to it. Fig. 3 presents the dose distribution and DVH of the clinical plan-
ners, who provided an average treatment plan based on the PQM score for Case 3,
which had the greatest improvement in treatment planning after referring to the
Feasibility DVHTM tool.
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Fig. 3. Dose distribution and dose volume histogram of clinical planners who were average treatment plans with PQM scores of Case 3, which had the most significant
improvement in treatment planning before (a) and after (b) referring to the Feasibility DVHTM tool.
PQM: Plan Quality Metric.
Differences among treatment planners
Twenty-five treatment plans resulted from each planner implementing 5
prostate treatment plans. Fig. 4 shows the differences between treatment plans cre-
ated before and after referring to the Feasibility DVHTM tool. The treatment plans
with the lowest and highest mean PQM scores created before referring to the Fea-
sibility DVHTM were those of Students B and A, respectively. After referring to the
Feasibility DVHTM tool, the mean PQM scores improved for 4 of 5 treatment plans.
Of these, the PQM score for clinical planners improved most significantly. In ad-
dition, the variation in PQM scores decreased for Students B and C. Concurrently,
the mean PQM score of student A obtained after referring to the Feasibility DVHTM
tool was lower than that obtained before referring to it. Fig. 5 shows the dose dis-
tribution and DVH of Case 4, prepared by student A, whose average PQM score
after referring to the Feasibility DVHTM tool was lower than that before referring
it. The clinical planners’ average treatment plan (the treatment planner who had
the greatest improvement in treatment planning after referring to the Feasibil-
ity DVHTM ) was that of Case 3. The dose distribution and DVH of Case 3 before
and after referring to the Feasibility DVHTM tool for clinical planners are shown in
Fig. 3.
Discussion
Fried et al.11 reported that in VMAT planning for 10 head and
neck cancer patients, referring to the Feasibility DVHTM tool helped
reduce the dose to both the contralateral parotid and larynx, re-
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sulting in a significant difference despite multiple hypotheses test-
ing. Recently, PlanIQTM has been integrated into a TPS different
from the one used in the present study; Perumal et al.12 and Xia
et al.13 reported the effectiveness of the Feasibility DVHTM tool in
this context. Perumal et al.12 developed 2 VMAT plans before and
after referring to the Feasibility DVHTM tool in cases of brain, head
and neck, lung, abdomen, and prostate cancers, and compared the
dosimetry results. Both plans met the dose constraint to the OAR.
However, the authors observed that the treatment plan obtained
after referring to the Feasibility DVHTM tool achieved better dose
reduction to the OAR without compromising the target coverage
than did the treatment plan obtained before referring to this tool.
The authors also reported that when the clinical target doses pro-
posed by the Feasibility DVHTM tool were used in their TPS opti-
mization, the treatment plans’ quality (OAR sparing) could be sig-
nificantly improved without involving many iterative steps.
Meanwhile, Xia et al.13 examined 3 treatment plans for 10 pa-
tients with lung cancer, including a clinically validated manual
treatment plan, a treatment plan obtained using a TPS, a generic
script, and a treatment plan created using personalized treatment
planning parameters based on the Feasibility DVHTM tool. The au-
thors reported that the last treatment plan was associated with
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Fig. 4. Comparison of PQM scores per planners before (a) and after (b) referring to the Feasibility DVHTM tool. PQM: Plan Quality Metric.

Fig. 5. Dose distribution and dose volume histogram for Case 4, the average treatment plan for student A’s PQM score, where the average PQM score was lower before (a)
and after (b) referring to the Feasibility DVHTM tool. PQM: Plan Quality Metric.

the highest dose reduction to the normal lung. Though the sites
were different in the present study, the customized treatment plan
based on the Feasibility DVHTM tool showed a similar tendency.
The present study investigated the effect of referring to the Fea-
sibility DVHTM tool on treatment plans prepared by four students
and a clinical planner for five prostate cancer patients. Case 4, in
which no improvement in PQM scores was observed, involved the
highest urinary bladder capacity of all cases, which exceeded 400
cm3 . Moreover, the overlap between the PTV and the rectum was
of a lesser extent in this than in the other cases. Therefore, the
quality of the treatment plan before referring to the Feasibility
DVHTM tool was already high; in fact, the treatment plan was close
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to the ideal DVH (achieving dose reduction to the OAR while en-
suring a sufficient dose to the PTV).
The present findings suggest that the Feasibility DVHTM tool
may improve the quality of treatment plans developed by treat-
ment planners without relevant clinical experience, including un-
dergraduate and graduate students, possibly compensating for the
lack of expertise. Nevertheless, the present findings indicate that
the clinical planner’s PQM scores improved the most (Fig. 4), which
may be accounted for by their experience in treatment planning
alongside their clinical knowledge. However, the plans of students
A and B included dose distribution that exceeded 50% of the pre-
scribed dose for a portion of the posterior rectal wall both before
and after referring to the Feasibility DVHTM tool (Figs. 2 and 5).
In another instance, no part of the posterior rectal wall exposed to
over 50% of the prescribed dose before or after referring to the Fea-
sibility DVHTM tool (Fig. 3). This suggests that planners with clini-
cal experience verify the dose distribution after treatment planning
using the slice-by-slice method, in contrast to students, who do
not perform a similar check. These findings indicate that students
should be trained to verify the dose distribution slice-by-slice after
obtaining a treatment plan.
This study has some limitations. This study involved students
within a year of graduation. Due to the on-going coronavirus dis-
ease 2019 pandemic, the students were banned from campus for 2
months (August to September 2020) to control the disease spread.
As a result, the duration of our study was shortened; data were
collected within 2 months. Further, each treatment planner was
allowed a limited number of hours per treatment plan due to re-
stricted access to planning equipment. As a result, we could only
include 5 prostate cancer cases. Future studies should be larger
and include at least 10 cases. In this study, student A referred to
the Feasibility DVHTM tool, which decreased and varied the mean
PQM score. Increasing the number of cases may reduce the ef-
fect of case dependence and improve the PQM scores. In addi-
tion, though this study focused on prostate cancer, additional stud-
ies interrogating treatment plans for other types of cancer are re-
quired, as the impact on the associated treatment plans may be
different.
The version of Eclipse (11.0.31) used in this study requires ap-
proximately 1 hour per treatment plan per case for the optimiza-
tion of VMAT planning and calculation of dose distribution. The
restrictions associated with the pandemic made it difficult to pro-
vide participants with sufficient time for treatment planning, re-
sulting in the average time per case of 3 hour. Consequently, it was
difficult to create multiple treatment plans and conduct a trial-
and-error analysis. Future studies involving equipment capable of
graphics processing unit-based dose calculation may help achieve
higher treatment plan quality.
Conclusions
In this study, improvement in the treatment plan was observed
in 4 of 5 prostate cancer cases. In addition, 4 of 5 treatment plan-
ners showed an improved treatment plan. The present findings
suggest that referring to the Feasibility DVHTM tool may improve
[mUS5Gb;May 7, 2021;18:13]
the quality of treatment plans for different types of planners and
patients. However, planners at any level of experience should be
trained to check the dose distribution in addition to checking the
DVH.
Funding
None declared.
Conflicts of Interest
Yuji Nakaguchi is an employee of TOYO MEDIC CO., LTD.
Acknowledgments
The authors would like to thank Yosuke Kano and Kenta Kita-
gawa of the Graduate School of Health Sciences, Tokushima Uni-
versity, and Yuto Endo and Shoji Ueda of the School of Health Sci-
ences, Tokushima University, for their cooperation in the treatment
plan of this study.
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