Systematic Quantitative Evaluation of Plan-IQ for Intensity-Modulated Radiation Therapy After Modified Radical Mastectomy

doi:10.21203/rs.3.rs-546727/v1

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Research Article

Systematic Quantitative Evaluation of Plan-IQ for Intensity-Modulated Radiation Therapy After Modified Radical Mastectomy

https://doi.org/10.21203/rs.3.rs-546727/v1

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Background and purpose: A systematic quantitative evaluation of the quality change of intensity-modulated radiation therapy (IMRT) using the Plan-IQ feasibility tool was performed for modified radical mastectomy.

Materials and methods: We selected 50 patients with breast cancer treated with IMRT. All patients received the same dose in the planning target volume (PTV). Two plans were designed for each patient: the clinically accepted normal plan group (NP group) and the repeat plan group (RP group). An automated planning strategy was generated using a Plan-IQ feasibility dose volume histogram (FDVH) in RP group. These plans were assessed according to the dosimetry parameters. A detailed scoring strategy was based on the RTOG9804 report and 2018 National Comprehensive Cancer Network guidelines, combined with clinical experience.

Results: PTV coverage in both groups was achieved at 100% of the prescribed dose. Except for the thyroid coverage, the dose limit of organs at risk (OAR) in RP group was significantly better than that in NP group. In the scoring analysis, the total score of RP group decreased compared to that of NP group (P < 0.05), and the individual scores of PTV and OAR significantly changed. PTV score in RP group decreased (P < 0.01); however, OAR score improved (P < 0.01).

Conclusions: The Plan-IQ FDVH was useful for evaluating a class solution for IMRT planning. Plan-IQ can automatically help physicians design the best OAR protection plan, which sacrifices part of PTV, while still meeting clinical requirements.

Cancer Biology

Oncology

Breast cancer

Intensity-modulated radiation therapy

Plan-IQ

Feasibility dose volume histogram

Breast cancer is a common malignancy in women, accounting for approximately 30% of new cancer cases in all women in the United States (1). Modified radical mastectomy is the primary treatment for patients with breast cancer. Radiotherapy (RT) after a radical mastectomy effectively increases the local control rate and reduces the mortality of patients with breast cancer (2–5). According to the recommendations of the National Comprehensive Cancer Network (NCCN) and Radiation Therapy Oncology Group (RTOG), patients with a high risk of local recurrence need RT after mastectomy.

Intensity-modulated radiation therapy (IMRT) and volumetric modulated arc radiotherapy (VMAT) have been widely used to treat malignancies. IMRT can improve the tumor control rate and patient survival by increasing the dose in the target area and reducing the dose to organs at risk (OAR) (6–8). Many studies on IMRT after modified radical mastectomy have benefited many patients (9, 10). During the design of the radiotherapy plan, we sought to minimize the dose to the normal tissues and optimize the prescribed dose coverage, homogeneity, and conformal degree of the area (planning target volume (PTV)). However, the process of dose optimization using IMRT is affected by several factors, which results in a significant difference in the quality of regimens (11). Most steps involved in generating the anatomical structure and optimizing the treatment plan can be automated. The use of automatic planning can reduce human variability to achieve predefined target dose goals.

Plan-IQ feasibility (Beijing HGPT Technology & Trade Corporation, China) is a tool that can estimate the best sparing dose of OAR before optimizing the plan (12). Plan-IQ can predict OAR dose using a model that takes a3-dimension dose clouds built outside targets as a benchmark to reflect the properties of radiation distribution observed in the media (13–15). Its automated optimization process can reduce level differences between physicians, which cannot be achieved using dose volume histogram parameters (DVH). In this study, Plan-IQ was used to guide the modification of the organ dose optimization limit of IMRT. The systematic quantification of FDVH was used to describe the changes in plan-IQ on the quality of IMRT plans.

2.1 Patients

Female patients with breast cancer who received IMRT were selected from our department between January 2018 to August 2020. Fifty patients received preventive RT with PTV; the prescribed dose was 50 Gy in 25 fractions. This study is a retrospective study, informed consent was exempted because the study did not harm patients by the Ethics Committee of the First Hospital of Jilin University. There are not conflicting interests with the other ethical parameters.

2.2 Image data and position fixation

Patients were placed on a CIVICO carbon fiber RT bed. They were placed according to the following methods: (1) the patients were placed supine; (2) the patients’ head was supported by a B to E Styrofoam soft pillow and tilted slightly toward the healthy side; (3) both arms were placed on the special fixing bracket, and both hands were placed on the forehead; (4) the irradiation area was covered with 1.0 cm equivalent tissue filler and fixed with thermally shrinkable peritoneum; and a 24-row spiral Siemens computer tomography (CT) was used to scan patients from the mandible to the navel during normal breathing with a slice thickness of 5 mm and a plane voxel size of 1 mm × 1 mm, and then uploaded to the Philips [email protected] treatment planning system for 3D image reconstruction. The CT image was uploaded to the dedicated RT server of Varian to design the RT plan.

2.3 Delineation of RT targets and OAR

According to the NCCN guidelines 2018 and report No.9804 of RTOG, the clinical target volume (CTV) and relevant OAR were contoured by qualified radiation oncologists:

Chest wall target: The upper boundary was located at the edge of the collar bone head down to 1 cm, connecting with the supraclavicular field. The lower boundary was 2 cm below the undamaged breast plica. The anterior boundary included the skin of the chest wall. The posterior boundary included the ribs and intercostal muscles. The inner bound was the midline of the body. The lateral border was the midaxillary line.

Target of supraclavicular lymphatic drainage: The upper boundary was the level of the cricothyroid membrane. The lower boundary was 1 cm below the lower margin of the clavicle head and connected to the chest wall. The inner boundary was the inner margin of the sternocleidomastoid, descending to the midpoint of the sternal notch. The outer boundary extended to the humeral head. Five millimeters were added to the three-dimensional margin of the CTV to obtain PTV.

OAR: ipsilateral lung, heart, thyroid, spinal cord, shoulder joint-R, breast-R, esophagus, trachea, and intestines.

2.4 Prescription dose of PTV and dose limitation for OAR

The planning objectives for PTV were the relative volume that received ≥ 100% of the prescribed dose > 95%, and the maximum point dose was < 110% of the prescribed dose. The dose coverage and homogeneity of PTV were assessed based on the dose distribution, DVH, and the trade-off between the dose delivered to PTV and OAR sparing. The planning objectives for OARs were as follows: ipsilateral lung, receiving more than 20 Gy (V₂₀) < 20%, receiving more than 10 Gy (V₁₀) < 25%, receiving more than 5 Gy (V₅) < 35%; volume of heart receiving more than 40 Gy (V₄₀) < 30% and that receiving more than 30 Gy (V₃₀) < 40%; mean dose of heart (D_mean) < 10 Gy; breast-R: a dose of 1 cubic centimeter volume (D_1cc) < 5 Gy.

2.5 Planning design

Two plans were designed for each patient: the clinically accepted normal plan group (NP group) and the repeat plan group (RP group). An automated planning strategy was generated in RP group using a Plan-IQ feasibility dose volume histogram (FDVH), which is a radiotherapy planning analysis software. Both NP and RP groups were subjected to single fixed field irradiation. For each enrolled patient, the layout of the beam, the dose prescription of PTV, and the initial optimization parameters of each OAR were set by loading a predefined technical script during the planning process. The lower bound part of the target was illuminated by penetrating irradiation with four supplementary upper oblique angles, whereas the upper part was illuminated by 5-field and half-field irradiation.

2.6 Plan evaluation

To comprehensively evaluate the changes in PTV and OAR dosimetry parameters and evaluate the quality of IMRT plans, we set up a new plan quality metric (PQM) (11), which was defined according to the existing PQM, RTOG 9804 report, NCCN guidelines 2018, and our clinical experience (Supplement Table S1).

Target dosimetry parameters included the volume reaching the prescribed dose (V_RX), homogeneity index (HI), and conformal index (CI). V_RX= PTV volume (cc) covered by specified dose (50 Gy)/ total PTV volume. HI = D₁ / D₉₉, where D₁ is the dose received by 1% of the target volume, and the rest by analogy. CI = (Vt, ref/Vt) × (Vt, ref/Vref), where Vt is the volume of PTV, Vt. ref is the volume of PTV wrapped around the isodose curve of the prescription dose (50 Gy), and Vref is the volume of all areas wrapped around the isodose curve of the prescription dose (50 Gy). The closer the CI is to 1, and the HI value is to 0, the better the uniformity and conformality of PTV. OAR dose assessment included D_mean of the heart, D_max (maximum dose in the target area) of healthy breast, average dose (V₅, V₁₀, V₂₀, D_mean) of the affected lung, D_mean and D_max of the humeral head-L, and thyroid and monitor unit (MU).

2.7 Statistical analysis

The experimental data in this study were collated using Microsoft office and statistically analyzed using PASW Statistics 22 and SPSS 22.0. The measurement data are expressed as the mean ± standard deviation (SD). If the comparison between NP and RP groups conformed to a normal distribution, the paired t-test was used, whereas the non-parametric test was used if the comparison did not accord with normal distribution. The significance level was set at p < 0.05.

3.1 The dose distribution in the target area

The dose distributions in the two groups are presented in Table 1 and Fig. 1. PTV in both groups that were irradiated at 100% of the prescribed dose approached 50 Gy. The V_RX of NP group (94.79 ± 0.93 %) was higher than that of RP group (94.37 ± 0.88 %) and was statistically significant (t = -4.57, P < 0.01). The CI and HI of NP group (0.72 ± 0.04; 0.1 ± 0.02) were significantly higher than those of RP group (0.66 ± 0.05; 0.13 ± 0.02) (t = -12.99, P < 0.01; t =-6.14, P < 0.01). However, V₅₅ (110% of the prescribed dose by volume) and D_mean of RP group (1.97 ± 1.82 %; 52.45 ± 0.33 Gy) were higher than those of NP group (0.19 ± 0.31 %; 51.9 ± 0.24 Gy) with statistical significance (t = -6.14, P < 0.01; t = -6.14, P < 0.01).

Table 1

Dosimetry comparison for the PTV of RP group and NP group (Mean ± SD)
PTV	n	RP group	NP group	t	P
V_RX	50	94.37 ± 0.88	94.79 ± 0.93	-4.57	0.00^a
CI	50	0.66 ± 0.05	0.72 ± 0.04	-12.99	0.00^a
HI	50	0.13 ± 0.02	0.1 ± 0.02	-6.14	0.00^b
V₅₅	50	1.97 ± 1.82	0.19 ± 0.31	-6.14	0.00^b
Dmean	50	52.45 ± 0.33	51.9 ± 0.24	-6.14	0.00^b

*a = Paired t test, *b = Nonparametric Wilcoxon test, P<0.05

3.2 The improvement of dose to OAR

We chose ipsilateral lung of one patient as an example. In Fig. 2, we set F as 0.00, 0.10, 0.12, and 0.50, respectively, and marked the red, dark yellow, dashed, and light yellow lines. The area below each line represented the average dose to ipsilateral lung. The green region was considered easy to achieve; yellow was challenging; orange was difficult; red was hard to achieve if PTV was not sacrificed. The gray line represented the FDVH curve of the affected lung of NP group, whereas the dashed line represented that of RP group when F = 0.12. Compared with the two curves, V₂₀ in the yellow region of great concern was lower in RP group than in NP group.

The doses of the other OARs are shown in Table 2. In both groups, V₂₀, V₁₀ and D_mean in ipsilateral lung were lower in RP group (19.56 ± 2.45 %; 31.01 ± 3.06 %; 10.68 ± 1.09 Gy) than those in NP group (22.1 ± 2.06 %; 32.16 ± 2.84 %; 11.45 ± 1.02 Gy) with statistical significance (t = -6.15, P < 0.01; t = -4.20, P < 0.01; t = -6.14, P < 0.01). However, V₅ of RP group (45.83 ± 4.56 %) was higher than that of NP group (44.9 ± 3.48 %) and was statistically significant (t = 2.38, P < 0.05). All D_mean of the heart, breast-R; shoulder joint-L, trachea, esophagus, intestine in RP group (4.95 ± 1.72 Gy; 11.19 ± 7.17 Gy; 7.93 ± 2.2 Gy; 6.79 ± 2.04 Gy; 3.94 ± 1.88 Gy; 7.59 ± 5.85 Gy) were lower than those in NP group (5.38 ± 1.88 Gy; 17.27 ± 12 Gy; 12.38 ± 2.53 Gy; 7.51 ± 3.25 Gy; 4.3 ± 2.55 Gy; 12.46 ± 10.89 Gy) with statistical significance (t = -3.68, P < 0.05; t = -4.79, P < 0.01; t = -15.34, P < 0.01; t = -2.48, P < 0.05; t = -1.68, P < 0.05; t = -4.53, P < 0.01). Although D_mean of the thyroid was higher in RP group (15.25 ± 4.82 Gy) than in NP group (14.6 ± 4.9 Gy), the difference was statistically insignificant (t = -1.38, P = 0.17). In addition, all D_max values of the spinal cord, shoulder joint-L, trachea, and intestines were lower in RP group than in NP group (t = − -6.02, P < 0.01; t = − -13.71, P < 0.01; t = − -4.02, P < 0.01; t = − -2.15, P < 0.05). However, D_max of the thyroid in RP group (47.26 ± 8.9 Gy) was higher than that in NP group (45.47 ± 7.89 Gy) (t = -3.66, P < 0.01). Although D_max of the esophagus in RP group (28.89 ± 12.76 Gy) was lower than that in NP group (30.78 ± 12.41 Gy), the difference was statistically insignificant (t = -2.06, P = 0.05).

Table 2

Dosimetry comparison for the OAR of RP group and NP group (Mean ± SD) (cGy)
OAR		n	RP group	NP group	t	P
Ipsilateral lung	V_20Gy	50	19.56 ± 2.4	22.1 ± 2.06	-6.15	0.00^b
	V_10Gy	50	31.01 ± 3.06	32.16 ± 2.84	-4.20	0.00^b
	V_5Gy	50	45.83 ± 4.56	44.9 ± 3.48	2.38	0.02^a
	D_mean	50	10.68 ± 1.09	11.45 ± 1.02	-6.14	0.00^b
Heart	D_mean	50	4.95 ± 1.72	5.38 ± 1.88	-3.68	0.01^a
Breast-R	D_mean	50	11.19 ± 7.17	17.27 ± 12	-4.79	0.00^b
Spinal cord	D_max	50	13.62 ± 3.16	22.67 ± 5.7	-6.02	0.00^b
shoulder joint-L	D_mean	50	7.93 ± 2.2	12.38 ± 2.53	-15.34	0.00^a
shoulder joint-L	D_max	50	20.06 ± 7.84	32.63 ± 7.74	-13.71	0.00^a
Thyroid	D_mean	50	15.25 ± 4.82	14.6 ± 4.93	-1.38	0.17^b
Thyroid	D_max	50	47.26 ± 8.9	45.47 ± 7.89	-3.66	0.00^b
Trachea	D_mean	50	6.79 ± 2.04	7.51 ± 3.25	-2.48	0.02^a
Trachea	D_max	50	19.83 ± 8.46	22.85 ± 10.11	-4.02	0.00^a
Esophagus	D_mean	50	3.94 ± 1.88	4.3 ± 2.55	-1.68	0.01^b
Esophagus	D_max	50	28.89 ± 12.76	30.78 ± 12.41	-2.06	0.05^a
Intestines	D_mean	50	7.59 ± 5.85	12.46 ± 10.89	-4.53	0.00^b
Intestines	D_max	50	32.58 ± 19.06	36.84 ± 18.78	-2.15	0.03^b

*a = Paired t test, *b = Nonparametric Wilcoxon test, P<0.05

MU value of the IMRT plan designed in RP group (899.7 ± 120.89 MU) was higher than that in NP group (752.34 ± 111.43 MU) (t = 10.65, P < 0.01). The data are presented in Table 3.

Table 3

Dosimetry comparison for the MU of RP group and RP group (Mean ± SD)
Group	n	MU
RP group	50	899.7 ± 120.89
NP group	50	752.34 ± 111.43
t		10.65
P		0.00^a

*a = Paired t test, *b = Nonparametric Wilcoxon test, P<0.05

3.3 Scores of plans

We quantitatively evaluated PTV and OAR of all patients (Table 4). OAR score of RP group (66.65 ± 8.10) was higher than that of NP group (59.01 ± 11.41) (t = -6.028, P < 0.01), whereas PTV score of RP group (37.72 ± 6.52) was inferior to that of NP group (47.99 ± 3.91) (t = -6.144, P < 0.01). In both groups, the comprehensive OAR and PTV scores of NP group (107.00 ± 13.13) were higher than those of RP group (104.37 ± 12.64) with statistical significance (t = -2.49, P < 0.05).

Table 4

Evaluation comparison for the score of RP group and NP group (Mean ± SD)
Structure	NP group	RP group	t	p
Total score	107.00 ± 13.13	104.37 ± 12.64	-2.486	0.013^a
PTV score	47.99 ± 3.91	37.72 ± 6.52	-6.144	0.000^a
OAR score	59.01 ± 11.41	66.65 ± 8.10	-6.028	0.000^a

*a = Paired t test, *b = Nonparametric Wilcoxon test, P < 0.05

Breast cancer occurring in the breast epithelium ranks first among female malignant tumors (16, 17). RT can reduce the local recurrence rate and improve the effective survival rate of patients with high-risk factors (18, 19). The application of IMRT allows the postoperative tumor bed area to receive an adequate dose of preventive radiation and reduce radiation to OAR. Many researchers have studied the application of Plan-IQ in RT planning design and pointed out that it further protects OAR, which was also confirmed in our study (13–15, 20). Some researchers have used PQM on the dosimetric parameters of the entire RT plan to quantitatively evaluate the change in the RT plan quality from a macroscopic perspective (21–25). However, no study has separated the PQM score into PTV and OAR parts to evaluate IMRT planning after modified radical mastectomy. To quantitatively evaluate the quality of IMRT plans in the two groups, we scored PTV and OAR and allocated each measure a maximum score of 20 according to the rating scale we set up.

OAR dose limits of the 50 cases of IMRT plan fully met the requirements of the RTOG and NCCN guidelines. We optimized the dose limit of OAR by referring to the FDVH. The D_mean, V_20, and V₁₀ of ipsilateral lung in RP group were significantly improved than those in NP group, including a decrease of about 2.0 % in V₂₀ and approximately 1 Gy in D_mean. In the manual planning design, it was difficult for V₂₀ to exhibit a downward trend. However, our study showed that Plan-IQ could reduce V₂₀ while ensuring the prescribed dose of PTV and the safety of other OARs. However, the value of V₅ in RP group was approximately 1% higher than that in NP group. In the clinic, V₂₀ and D_mean are decisive factors in radiation pneumonia occurrence (26, 27). The increase in V₅ was less than 1%, whereas the significant decrease in V₂₀ and D_mean may bring more incredible benefits to the patients (28, 29).

The NCCN guidelines clearly indicate that the incidence of radiation-induced coronary heart disease can be reduced when D_mean of the heart is below 8 Gy (30). In our study, D_mean of the heart in RP group was below 7 Gy. Other OARs, such as the esophagus, main trachea, stomach, and intestine, with smaller irradiated volume, easily were ignored during design planning, but Plan-IQ accounted for all OARs. The protection in RP group for the breast-R, spinal cord, humeral head, trachea, esophagus, and intestines was apparently better than that in NP group. However, RP group did not show an advantage in the protection of the thyroid, possibly because we only emphasized the single parameter F. The dose of OAR in RP group was lower than that in NP group, but the coincidence degree with the predicted result of Plan-IQ was not perfect. This is mainly because Plan-IQ did not consider the type of planning system, the intensity modulation mode (IMRT or VMAT), and the multi-leaf collimator thickness when predicting the DVH of OAR. Although there were some shortcomings, Plan-IQ provided a significant improvement in OAR, which offers a new way for the physicist to solve the problem of the plan design. In addition, the optimized process of OAR inevitably led to longer treatment durations, which were reflected in an increase in MU and submitted more elaborate planning in RP group.

In the PQM score of PTV, the score of the RP plan decreased compared with NP group. It can be clearly seen from Fig. 1 that the main score losses are CI, HI, and V₅₅. The results also showed that RP group had an advantage in OAR while reducing CI, HI, and V₅₅ scores. As the dose of OAR decreased, the V₅₅ increased from 0.19 % to 1.98 %. In contrast, although OAR score in NP group was not as high as that of RP group, its score in PTV maintained an advantage. However, the difference in total scores between the two groups was only approximately 3 points. Although the score decreased, V_RX, the main parameter for evaluating PTV dosimetry, did not change significantly, and all PTV indicators were fully satisfied with the clinical requirements.

In this study, although the total score of RP group did not improve, the individual scores of PTV and OAR were significantly changed. PTV score in RP group dropped, but OAR score improved more. The score loss of PTV on CI, HI, and V₅₅ could be ignored compared with the protection of OAR. Our results also indicated that if we want to improve OAR further, we have to sacrifice the CI, HI, and V₅₅ of PTV. The introduction of Plan-IQ in the IMRT plan contributed to predicting the remaining reduction space of OAR dose limit, especially the V₂₀ and D_mean of the affected ipsilateral lung. Although the results come at the expense of CI, HI, and V₅₅ of PTV, it is still very beneficial to patients.

In conclusion, in the RT process after modified radical mastectomy, Plan-IQ can automatically help physicians design the best OAR protection plan, which sacrifices part of PTV, but still meets the clinical requirements. If further breakthroughs are to be made, clinicians need to decide on the balance between PTV and OAR to determine the next goal of the RT plan design. The plan quality scoring added an evaluation measure that quantified the plan quality of individual patients.

Conflict of Interest: None

Ethics approval and consent to participate: All experimental protocols were approved by the Ethics Committee of the First Hospital of Jilin University. This study is a retrospective study, all patients have received a standard accepted normal plan. An automated planning strategy was generated using a Plan-IQ after the treatment. There were no any harm to patients, so the informed consent was remission.

Consent for publication: All authors agree to publish the article

Funding Statement: This work was supported by the Jilin Provincial Science and Technology Foundation (Grant number 20190201200JC).

Data Availability Statement for this Work: We confirmed that all methods were carried out in accordance with the Ethics Committee of the First Hospital of Jilin University. Research data are stored in an institutional repository and will be shared upon request to the corresponding author.

Authors' contributions: X.J.: Conceptualization, Writing-review and editing, Funding acquisition. Z.Z.Z. and K.Z.C.: Software, Investigation, Writing-original draft preparation, Statistical Analysis. L.J.D., N.T., L.B.W. and W.M.X.: Software, Investigation. H.D.W.: Writing-original draft preparation.

Acknowledgements: We would like to thank Editage (www.editage.cn) for English language editing. We would like to thank Beijing HGPT Technology & Trade Corporation for providing the Plan-IQ system.

Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin. 2019;69(1):7-34.
Fogliata A, Seppälä J, Reggiori G, Lobefalo F, Palumbo V, De Rose F, et al. Dosimetric trade-offs in breast treatment with VMAT technique. Br J Radiol. 2017;90(1070):20160701.
Fiorentino A, Ruggieri R, Giaj-Levra N, Sicignano G, Di Paola G, Naccarato S, et al. Three-dimensional conformal versus intensity modulated radiotherapy in breast cancer treatment: is necessary a medical reversal? La Radiologia medica. 2017;122(2):146-53.
Liu H, Chen X, He Z, Li J. Evaluation of 3D-CRT, IMRT and VMAT radiotherapy plans for left breast cancer based on clinical dosimetric study. Computerized medical imaging and graphics : the official journal of the Computerized Medical Imaging Society. 2016;54:1-5.
Haciislamoglu E, Colak F, Canyilmaz E, Zengin AY, Yilmaz AH, Yoney A, et al. The choice of multi-beam IMRT for whole breast radiotherapy in early-stage right breast cancer. SpringerPlus. 2016;5(1):688.
Rogers CL, Won M, Vogelbaum MA, Perry A, Ashby LS, Modi JM, et al. High-risk Meningioma: Initial Outcomes From NRG Oncology/RTOG 0539. Int J Radiat Oncol Biol Phys. 2020;106(4):790-9.
Hörner-Rieber J, Forster T, Hommertgen A, Haefner MF, Arians N, König L, et al. Intensity Modulated Radiation Therapy (IMRT) With Simultaneously Integrated Boost Shortens Treatment Time and Is Noninferior to Conventional Radiation Therapy Followed by Sequential Boost in Adjuvant Breast Cancer Treatment: Results of a Large Randomized Phase III Trial (IMRT-MC2 Trial). Int J Radiat Oncol Biol Phys. 2020.
Desideri I, Loi M, Francolini G, Becherini C, Livi L, Bonomo P. Application of Radiomics for the Prediction of Radiation-Induced Toxicity in the IMRT Era: Current State-of-the-Art. Front Oncol. 2020;10:1708.
Ma C, Zhang W, Lu J, Wu L, Wu F, Huang B, et al. Dosimetric Comparison and Evaluation of Three Radiotherapy Techniques for Use after Modified Radical Mastectomy for Locally Advanced Left-sided Breast Cancer. Sci Rep. 2015;5:12274.
Yang B, Wei XD, Zhao YT, Ma CM. Dosimetric evaluation of integrated IMRT treatment of the chest wall and supraclavicular region for breast cancer after modified radical mastectomy. Medical dosimetry : official journal of the American Association of Medical Dosimetrists. 2014;39(2):185-9.
Nelms BE, Robinson G, Markham J, Velasco K, Boyd S, Narayan S, et al. Variation in external beam treatment plan quality: An inter-institutional study of planners and planning systems. Practical radiation oncology. 2012;2(4):296-305.
Xia W, Han F, Chen J, Miao J, Dai J. Personalized setting of plan parameters using feasibility dose volume histogram for auto-planning in Pinnacle system. Journal of applied clinical medical physics. 2020;21(7):119-27.
Perumal B, Sundaresan HE, Ranganathan V, Ramar N, Anto GJ, Meher SR. Evaluation of plan quality improvements in PlanIQ-guided Autoplanning. Reports of practical oncology and radiotherapy : journal of Greatpoland Cancer Center in Poznan and Polish Society of Radiation Oncology. 2019;24(6):533-43.
Fried DV, Chera BS, Das SK. Assessment of PlanIQ Feasibility DVH for head and neck treatment planning. Journal of applied clinical medical physics. 2017;18(5):245-50.
Ahmed S, Nelms B, Gintz D, Caudell J, Zhang G, Moros EG, et al. A method for a priori estimation of best feasible DVH for organs-at-risk: Validation for head and neck VMAT planning. Medical physics. 2017;44(10):5486-97.
Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin. 2015;65(2):87-108.
Winters S, Martin C, Murphy D, Shokar NK. Breast Cancer Epidemiology, Prevention, and Screening. Progress in molecular biology and translational science. 2017;151:1-32.
Cheng SH, Tsai SY, Yu BL, Horng CF, Chen CM, Jian JJ, et al. Validating a prognostic scoring system for postmastectomy locoregional recurrence in breast cancer. Int J Radiat Oncol Biol Phys. 2013;85(4):953-8.
Chen X, Yu X, Chen J, Yang Z, Shao Z, Zhang Z, et al. Radiotherapy can improve the disease-free survival rate in triple-negative breast cancer patients with T1-T2 disease and one to three positive lymph nodes after mastectomy. Oncologist. 2013;18(2):141-7.
Hoffmann M, Pacey J, Goodworth J, Laszcyzk A, Ford R, Chick B, et al. Analysis of a volumetric-modulated arc therapy (VMAT) single phase prostate template as a class solution. Reports of practical oncology and radiotherapy : journal of Greatpoland Cancer Center in Poznan and Polish Society of Radiation Oncology. 2019;24(1):92-6.
Clarke S, Goodworth J, Westhuyzen J, Chick B, Hoffmann M, Pacey J, et al. Software-based evaluation of a class solution for prostate IMRT planning. Reports of practical oncology and radiotherapy : journal of Greatpoland Cancer Center in Poznan and Polish Society of Radiation Oncology. 2017;22(6):441-9.
Ahmad I, Chufal KS, Bhatt CP, Miller AA, Bajpai R, Chhabra A, et al. Plan quality assessment of modern radiotherapy delivery techniques in left-sided breast cancer: an analysis stratified by target delineation guidelines. BJR open. 2020;2(1):20200007.
Choi SH, Park SH, Lee JJB, Baek JG, Kim JS, Yoon HI. Combining deep-inspiration breath hold and intensity-modulated radiotherapy for gastric mucosa-associated lymphoid tissue lymphoma: Dosimetric evaluation using comprehensive plan quality indices. Radiat Oncol. 2019;14(1):59.
Aliotta E, Nourzadeh H, Siebers J. Quantifying the dosimetric impact of organ-at-risk delineation variability in head and neck radiation therapy in the context of patient setup uncertainty. Physics in medicine and biology. 2019;64(13):135020.
Fusella M, Scaggion A, Pivato N, Rossato MA, Zorz A, Paiusco M. Efficiently train and validate a RapidPlan model through APQM scoring. Medical physics. 2018;45(6):2611-9.
Wang SL, Liao Z, Vaporciyan AA, Tucker SL, Liu H, Wei X, et al. Investigation of clinical and dosimetric factors associated with postoperative pulmonary complications in esophageal cancer patients treated with concurrent chemoradiotherapy followed by surgery. Int J Radiat Oncol Biol Phys. 2006;64(3):692-9.
Katsui K, Ogata T, Watanabe K, Katayama N, Soh J, Kuroda M, et al. Dose-volume parameters predict radiation pneumonitis after induction chemoradiotherapy followed by surgery for non-small cell lung cancer: a retrospective analysis. BMC cancer. 2019;19(1):1144.
Meng Y, Luo W, Wang W, Zhou C, Zhou S, Tang X, et al. Intermediate Dose-Volume Parameters, Not Low-Dose Bath, Is Superior to Predict Radiation Pneumonitis for Lung Cancer Treated With Intensity-Modulated Radiotherapy. Front Oncol. 2020;10:584756.
Tang X, Li Y, Tian X, Zhou X, Wang Y, Huang M, et al. Predicting severe acute radiation pneumonitis in patients with non-small cell lung cancer receiving postoperative radiotherapy: Development and internal validation of a nomogram based on the clinical and dose-volume histogram parameters. Radiother Oncol. 2019;132:197-203.
Darby SC, Ewertz M, McGale P, Bennet AM, Blom-Goldman U, Brønnum D, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. The New England journal of medicine. 2013;368(11):987-98.

No competing interests reported.

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Editorial decision: Major revision
06 Sep, 2021
Reviews received at journal
31 Aug, 2021
Reviewers agreed at journal
26 Aug, 2021
Reviewers agreed at journal
26 Aug, 2021
Reviewers invited by journal
23 Aug, 2021
Editor assigned by journal
19 Aug, 2021
Editor invited by journal
10 Jun, 2021
Submission checks completed at journal
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First submitted to journal
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You are reading this latest preprint version

Systematic Quantitative Evaluation of Plan-IQ for Intensity-Modulated Radiation Therapy After Modified Radical Mastectomy

Status:

Version 1

Abstract

Figures

1. Introduction

2. Materials And Methods

2.1 Patients

2.2 Image data and position fixation

2.3 Delineation of RT targets and OAR

2.4 Prescription dose of PTV and dose limitation for OAR

2.5 Planning design

2.6 Plan evaluation

2.7 Statistical analysis

3. Results

3.1 The dose distribution in the target area

3.2 The improvement of dose to OAR

3.3 Scores of plans

4. Discussion

5. Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1