Fraction-variant VMAT planning for patients with complex gynecological and head-and-neck cancer.

Clinical Snapshot

Key Findings

• P Value: Not specified

• Effect Size: Dosimetric benefit increased with number of different plans delivered

• Primary Outcome: Fraction-variant treatments achieved significantly better target coverage and reduced organ-at-risk doses compared to fraction-invariant treatments

• Nnt Or Sensitivity: 1-arc and 2-arc fraction-variant treatments approximated dosimetric quality of 3-arc fraction-invariant treatments while reducing delivery time

• Confidence Interval: Not reported

Clinical Application

Requires advanced treatment planning systems and specialized optimization algorithms; implementation complexity may limit adoption Relevant to major Australian cancer centres with VMAT capability; would require TGA consideration for software modifications and ACPSEM evaluation for clinical implementation Patients with complex gynecological and head-and-neck cancers requiring high-precision radiotherapy

Abstract

Objective. Increasing the number of arcs in volumetric modulated arc therapy (VMAT) allows for better intensity modulation and may improve plan quality. However, this leads to longer delivery times, which may cause patient discomfort and increase intra-fractional motion. In this study, it was investigated whether the delivery of different VMAT plans in different fractions may improve the dosimetric quality and delivery efficiency for the treatment of patients with complex tumor geometries.Approach. A direct aperture optimization algorithm was developed which allows for the simultaneous optimization of different VMAT plans to be delivered in different fractions, based on their cumulative physical dose. Each VMAT plan is constrained to deliver a uniform dose within the target volume, such that the entire treatment does not alter the fractionation scheme and is robust against inter-fractional setup errors. This approach was evaluated in-silico for five patients with gynecological and five patients with head-and-neck cancer.Main results. For all patients, fraction-variant treatments achieved significantly better target coverage and reduced the dose to critical organs-at-risk compared to fraction-invariant treatments that deliver the same plan in every fraction, where the dosimetric benefit was shown to increase with the number of different plans to be delivered. In addition, 1-arc and 2-arc fraction-variant treatments could approximate the dosimetric quality of 3-arc fraction-invariant treatments, while reducing the delivery time.Significance.Fraction-variant VMAT treatments may achieve excellent dosimetric quality for patients with complex tumor geometries, while keeping the delivery time per fraction viable.

References

1. 1.Torelli, N., Day, M., & Unkelbach, J. (2026). Fraction-variant VMAT planning for patients with complex gynecological and head-and-neck cancer. Physics in Medicine and Biology. https://doi.org/10.1088/1361-6560/ae5869