1

The implementation of RapidPlan in predicting deep inspiration breath hold candidates

with left-sided breast cancer
Aubrie Rice, BS, RT(T); Ian Zoller, BS, RT(T); Kevin Kocos, MEd; Dannyl Weller, BS;
Dominic DiCostanzo, MS, DABR; Ashley Hunzeker, MS, CMD; Nishele Lenards PhD, CMD,
RT(R)(T), FAAMD

ABSTRACT
The aim of this study was to determine if RapidPlan (RP), a knowledge based treatment planning
tool, could be used as a prediction method to determine which left-sided supine breast cancer
patients would benefit from the deep inspiration breath-hold (DIBH) technique. A RP model
database was created with 72 clinically approved 3D conformal radiation therapy (3D-CRT)
treatment plans. This model was validated by introducing 10 new patient datasets, creating RP
generated plans and comparing the clinically approved plan for the corresponding patient. The
R2 value, which measures the degree of correlation and ranges from 0 to 1, was computed for
heart, ipsilateral lung and contralateral breast. A strong correlation was observed between the
heart and lung constraints showing R2 values of: 0.8025 (dose to 5% of the heart [D 5 ]), 0.8216
(dose to 35% of the heart [D 35 ]), 0.8206 (heart mean dose), 0.9789 (volume of the lung receiving
20 Gy [V 20 ]), 0.9788 (volume of the lung receiving 10 Gy [V 10 ]), 0.9835 (volume of the lung
receiving 5 Gy [V 5 ]). A weak correlation was found within the model for the volume of the
contralateral breast receiving 3 Gy (V 3 ) with an R2 value of 0.5781. The prediction ability of the
model was then tested on the free-breathing (FB) scans of patients with clinically approved
DIBH plans totaling 29 patients and results were then compared to the FB clinical plan attempts.
When comparing RP predicted and RP generated plans, a strong correlation was observed for the
lung constraints with the strongest correlation defined for V 20 of the left lung with an R2 value of
0.8916. When comparing RP generated plans and clinically attempted plans, a strong correlation
was observed for the heart mean dose which resulted in an R2 value of 0.914 and a p-value of
2.90E-19. A slope formula was generated from the trend line between these values (y = 1.1137x +
0.1217) and applied to the RP generated plan values. The formula outcome was compared to the
clinically attempted plan values. This comparison showed a standard deviation of 48.6 cGy. It
was concluded that with the created model and using the physician planning target volume
(PTV), RP generated plans could accurately predict mean heart dose within 50 cGy. After
 2

validating the link between physician PTV and mean heart dose, the model was tested clinically
by inserting Test PTV Evals that were contoured by the researchers as a surrogate for
predicting mean heart dose. Test PTV Eval contours were drawn based on clinical reference
wires placed by the physician during simulation and were extracted 3 mm (chestwall) or 5 mm
(breast) from the skin surface to exclude the dose buildup region. A regression analysis was
performed on all recorded values deeming the most correlated values as the RP generated plan
versus the clinical plan for the D 5 of the heart and for the mean heart dose with R2 coefficients of
0.9134 (Heart D 5 ) and 0.8811 (mean heart dose). The slope formula (y = 1.0174x - 9.067) was
applied to the RP generated plan values and the outcome was compared to the clinically
attempted plan values. This comparison showed a standard deviation of 27.2 cGy. It was
concluded through clinical testing that with a Test PTV Eval, the RapidPlan generated plans
were able to predict mean heart doses within 30 cGy.

Keywords: Left-sided breast cancer, RapidPlan, free-breathing (FB), deep inspiration breath-
hold (DIBH)

Introduction
Even with the benefits of radiation therapy (RT) in the treatment of breast cancer, it has
been shown that left-sided breast treatments can cause adverse cardiac health effects. One of
these complications is an increased risk of heart disease induced by RT.1-3 The development of
these cardiac morbidities depends on many factors such as dose to the heart, age at the time of
radiation treatment, and prognosis of the cancer. Aforementioned cardiac complications often
develop from the mechanism of coronary microvascular endothelial damage brought on
by substantial dose to the heart.2 Although exact dosing constraints to the heart are not yet
known, recent studies have focused on achieving a mean dose to the heart that is < 4 Gy.4
Although there have been significant improvements in RT techniques for breast cancer,
another complication arises from excess dose to the ipsilateral lung which can often be 2 to 3
times that of the contralateral lung dose.1 Darby et al1 compared the long-term mortality ratios
between left and right sided breast patients and showed an increase in mortality from heart and
lung cancer following radiation therapy to the left-sided group. This has been replicated in
 3

several other studies indicating significantly increased levels of secondary lung cancer in the
ipsilateral lung occurring 10-20 years post RT for breast cancer patients.1-5
A treatment technique designed to combat these complications is the use of DIBH. This
technique was designed to elevate the chest wall so that there is a separation between the breast
and adjacent organs at risk (OAR). One systematic review indicated that DIBH can decrease the
mean heart dose by approximately 3.4 Gy, resulting in a 13.6% reduction in the risk of
developing heart disease.6 This result has been verified by numerous other studies, showing that
DIBH is an effective means of reducing lung and heart doses when compared to FB treatments.7-
9

Yet, even with the published benefits of utilizing DIBH over FB for left-sided breast
patients, drawbacks still exist. Deep inspiration breath-hold can be more challenging to
reproduce on a daily basis and has been shown to result in higher contralateral breast dose.10 For
these reasons, some cancer centers tend to perform CT simulation with both FB and DIBH CT
scans with the intention of using the FB CT for planning purposes due to ease of reproducibility.
If the FB plan fails to achieve normal tissue constraints, then the plan will be recreated on the
DIBH CT in order to lower the normal tissue dose. This process creates a major decrease in
efficiency, often requiring multiple plans to be created before knowing which technique will be
used for the final treatment plan.
To help solve the problem of inefficiency, efforts have been made to find a method for
predicting which patients would benefit from using DIBH prior to creating a treatment
plan. Studies have been completed attempting to evaluate anatomical metrics from patient CT
scans to find a dependable way to determine which patients would require the use of the DIBH
technique.11,12 These studies were unsuccessful in determining a reliable anatomical parameter
that was useful and oftentimes required the addition of treatment fields.
Recently in the field of medical dosimetry, knowledge based treatment planning (KBP)
has become increasingly used to improve planning efficiency. RapidPlan (Varian Medical
Systems, Palo Alto, CA) is a commercially available KBP tool that provides the practitioner with
a predicted dose-volume histogram (DVH) prior to intensity modulated radiation therapy
(IMRT) optimization. In order for RP to generate a DVH, a database of previous treatment plans
for patients of a specific disease site needs to be created. RapidPlan extracts the DVH
information for assigned OAR from plans included within the database and then uses this
 4

information for new patients by creating optimization objectives based on target and OAR
geometries.
Knowledge based planning has been researched for various disease sites such as head and
neck, lung, esophagus, spine, liver and pelvic cancers.13-18 In the majority of these studies, RP
generated quality IMRT plans with equivalent target coverage and improved organ sparing when
compared to clinically achieved IMRT plans. Since RP is a tool for IMRT optimization, no
studies have been completed utilizing a database consisting of conformal treatment plans. The
objective of this study was to determine if RP could be used as a reliable prediction method to
determine left-sided supine breast cancer patients that would benefit from the DIBH technique.
Methods and Materials
Patient Selection
All patients selected for this study were treated for left-sided breast cancer at the same
radiation oncology clinic. Patients were treated in the supine position with either a FB or DIBH
technique. Patients without lymph node involvement underwent treatment solely to the affected
breast. Those with nodal involvement received treatment to the breast or chestwall (post
mastectomy) with irradiation of regional lymph nodes. Regional nodal irradiation included the
supraclavicular, axillary and internal mammary lymph node (IMN) groups. Patients treated with
IMRT or treated in the prone position were not included within the scope of this study.
During simulation, each patient underwent a FB and DIBH CT scan on a Qfix breast
board with the arms overhead (Figure 1). A Vaclok bag was positioned under the left arm for
further immobilization of the affected side (Figure 2). Once properly immobilized, the patient
underwent both FB and DIBH simulation techniques using a GE Discovery scanner with 2.5 mm
axial slice thickness. For the DIBH scan, Varian Real-Time Position Management (RPM)
respiratory gating was utilized. The RPM system was used to assess the breath hold position of
the patient to create an acceptable range to be reproduced for daily treatment.
Contouring
Following simulation, patient datasets were imported into the Eclipse treatment planning
system (TPS) for delineation of target volumes and OAR. Planning target volumes were
contoured by the physician as described in the Breast Cancer Atlas for Radiation Therapy
Planning.19 For intact breast patients without the inclusion of regional lymph nodes, PTVs
created included the Lumpectomy PTV and Breast PTV. For patients with treatment to the
 5

breast or chestwall with the inclusion of regional lymph nodes, the PTVs included: Lumpectomy
PTV, Breast PTV, Chestwall PTV, Mastectomy Scar PTV, Supraclavicular PTV, Axillary PTV,
and Internal Mammary Node PTV. Oftentimes the PTV expansion extended outside the skin
surface, requiring the structure to be cropped to exclude the dose buildup region. Therefore,
physicians created corresponding PTV Eval structures for more accurate dose
analysis. Organs at risk were contoured by the medical dosimetrist and included the heart,
ipsilateral lung, contralateral lung, contralateral breast, thyroid, sternum, esophagus and spinal
cord. These structures were also contoured as described in the Breast Cancer Atlas for Radiation
Therapy Planning.19
Treatment Planning
Treatment planning was completed utilizing a 3D-CRT technique and patient plans were
created using the Eclipse TPS. Depending on the stage of the disease and the decision of the
treating physician, patients were prescribed a dose of 50 Gy in 25 fractions, 42.56 Gy in 16
fractions, or 40 Gy in 15 fractions. Sequential boosts using electrons or photons were usually
prescribed for 10-14 Gy in 5-7 fractions to the lumpectomy or mastectomy scar. Treatments
were performed on a Varian Truebeam linear accelerator with treatment beam energies of 6 and
15 MV.
When determining the appropriate beam angles for the treatment plan, the proximity
of the contralateral breast, location of heart, left lung and PTV were all taken into account. This
was accomplished using the beams-eye view tool and finding the optimal angle to achieve
complete PTV coverage while avoiding the contralateral breast, heart and lung as much as
possible. The collimator rotation was dependent on several factors. If nodal volumes were
included, the plan was created using a mono-isocentric setup with a half-beam block. Collimator
angles for these plans were set to 0 to create a match line. If nodal volumes were not included,
collimator angles were dependent upon what would provide the most conformal blocking of the
heart and lung.
The constraints used for planning are outlined in the Radiation Therapy Oncology
Group (RTOG) 1005 and 1304 protocols and were dependent of the prescribed dose.20,21 The
goals for target coverage were to be satisfied while also meeting all the OAR constraints. If it
were impossible to meet the ideal objectives, then the acceptable variation was accepted.
Model Creation and Validation
 6

To create a comprehensive database, 72 manually created patient plans were exported

into RP. These plans were clinically approved and previously treated. The exported plans
consisted of 40 intact breast and 32 chest wall treatment plans. To create a model that was
representative of all patient anatomical geometries, patients with and without nodal involvement
were included in the database. Treatment plans included breast only plans (24), breast with
regional lymph nodes (12), chest wall with regional lymph nodes (32) and breast with axillary
lymph nodes (4). The database included 34 FB and 38 DIBH patient plans.
Structures from patient plans that were matched within the database for extraction of
DVH information included the contralateral breast, heart, left and right lung, PTV High (95% of
prescribed dose to 95% of the volume), PTV Low (90% of the prescribed dose to 90% of the
volume), sternum, and thyroid. Structures labeled PTV High included the Lumpectomy PTV
Eval, Breast PTV Eval, Chestwall PTV Eval, Mastectomy Scar PTV Eval, Supraclavicular PTV,
and Axillary PTV. The structure labeled PTV Low included the IMN PTV. Due to this nodal
group often being deep-seated within the chest and located close to the heart, coverage
requirements are lower as outlined in RTOG 1304.21 Studies have shown that recurrence within
the IMN lymph node chain is very rare even when the nodes are excluded from radiation
treatment fields altogether.22 For this reason, less coverage to the IMN PTV was justified.
Following the completion of the database, the model was trained using the clinical 3D-
CRT treatment plans. During training, RP analyzed the patient data and ran statistical measures
on the matched structures included within the database. One of these measures, the Cooks
distance, is a measure of how influential a data point is on the rest of the data. For this study,
any structure with a Cooks distance greater than 20 was excluded from the database to reduce
skewing of the model and to increase prediction accuracy. The model was then exported to
Varian Model Analytics to flag patient structures that were identified as outliers within the
model. All structures suggested to be excluded from the model were then removed and the
model was retrained.
To ensure that the trained model created accurate treatment plans, 10 new patient data
sets were introduced to create plans using the RP model. Previously approved patient plans that
were not used in the training of the model were used for validation. All patient plans were
copied so that all multileaf collimators (MLCs) and reduced fields could be deleted to allow for
optimization. The IMRT plans created with RP used the same oblique fields as in the clinical
 7

plans, approximating a field-in-field technique that would be used with 3D-CRT planning.
Treatment beam energies were changed to 10 MV photons to best approximate a mixed energy
treatment plan that would be used clinically. Photon optimization was completed using the
Photon Optimizer (PO) version 13.6.23 and dose calculations were performed using Acuros
External Beam version 13.6.23.
Prior to optimization, the created RP model was applied to each new patient dataset to
create a predicted DVH for the matched patient structures. Predicted dose-volume data values
were recorded for the heart, ipsilateral lung, and contralateral breast. The recorded constraints
for the heart included D 5 , D 35 , and the mean heart dose. Recorded lung data included V 20 , V 10 ,
and V 5 . The predicted dose-volume value recorded for the contralateral breast included the V 3
value. Finally, optimization was completed utilizing the optimization objectives shown in Table
1. The completed RP plan doses to the heart, left lung, and contralateral breast were compared to
the predicted and clinically achieved values.
Prediction Ability on FB Scans
After validating the performance of the RP model, RP generated plans were then created
from the FB CT scan for patients treated clinically using DIBH that were included within the RP
model. For these patients, planning had been attempted on the FB scan, but due to not meeting
heart constraints, the patient was replanned using the DIBH CT. From clinical experience, the
heart mean dose was usually the deciding factor as to why a patient was unable to be treated with
a FB scan. For this reason, only mean heart doses from clinical plans were recorded for
comparison to RP generated plans. The RapidPlan model was then used to create new plans
utilizing the same process described above during the model validation phase. In total, 29 new
patient plans were created using the FB CT data sets.
Clinical Testing
A clinical test was performed using 15 patients with clinically approved plans that were
not included within the model. Clinical testing included 8 breast-only patients and 7 patients
with nodal involvement. A corresponding Test PTV Eval structure was drawn by the researchers
for each patient based on the clinical reference wires along with guidelines from the Breast
Cancer Atlas for Radiation Therapy Planning.19 To maintain consistency, Test PTV Eval
contours were drawn to extend superiorly/inferiorly and medially/laterally from wire to wire and
were bordered posteriorly by the ribs (Figure 3). The Test PTV Evals were then extracted 3 mm
 8

(chestwall) or 5 mm (breast) from the skin surface to exclude the dose buildup region as stated in
RTOG 1005 and 1304.20,21
Gantry and collimator angles were set to the Test PTV Eval structure in order to limit the
amount of heart and left lung included within the field. For nodal patients, collimator angles
were set to 0 degrees in order to create a match line between the breast or chestwall and
supraclavicular fields. Nodal fields were set to standard gantry angles of 345 and 165 degrees to
limit the dose to the spinal cord. The RP model was then applied by matching only the left lung,
heart and Test PTV Eval contours. Optimization was completed using the same process
described in previous steps. For this test, RP predicted, RP generated, and clinical plan values
were recorded for the heart (D 5 , D 35 , mean dose) and left lung (V 20 , V 10 , and V 5 ).
Results
Model Validation
Upon analyzing the DVH data, RP generated statistics that were based from the matching
of patient structures to the corresponding structures within the existing model. For the purpose
of this study, structures that were flagged by the researchers for the evaluation of dose by RP
included the PTV high, PTV low, heart, left lung, right lung, contralateral breast, sternum and
thyroid. A regression analysis was performed by RP and a strong correlation was observed
between the heart, left lung, sternum and thyroid structures within the model. An R2 value was
computed for these structures and resulted in values of 0.867, 0.929, 0.869, and 0.950,
respectively (Table 2). The R2 values that are closer to 1 indicate a strong relationship between
data sets. This regression analysis is a measure of how accurately the model will predict doses to
new patients that are introduced to the model.
Following the completion of the RapidPlan generated patient plans, several values were
recorded including the RP predicted value, the RP generated plan value, and the clinical plan
value. To evaluate the correlation between these values, scatterplots were created and R2
coefficients were determined for each constraint that compared the RP generated plan and the
clinical plan values (Figure 4). A strong correlation was observed between the heart and lung
constraints with the strongest correlation obtained for V 20 of the left lung. The R2 values for
these constraints were as follows: 0.8025 (heart D 5 ), 0.8216 (heart D 35 ), 0.8206 (heart mean),
0.9789 (lung V 20 ), 0.9788 (lung V 10 ), 0.9835 (lung V 5 ). The only constraint that did not show a
strong correlation within the model was the V 3 for the contralateral breast which resulted in an
 9

R2 value of 0.5781. Upon evaluation of these results, it was concluded the model was valid for
further research.
Prediction Ability on FB Scans
Following the completion of the FB RapidPlan generated plans, predicted and generated
values were recorded. Along with these values, mean heart doses for the clinically attempted
plan were also recorded. A regression analysis was performed between the RP predicted and RP
generated plan values for the heart, left lung, and contralateral breast through the creation of
scatterplots and R2 coefficients (Figure 5). A strong correlation was observed for the lung
constraints with the strongest correlation found for the V 20 of the left lung with an R2 value of
0.8916. A poor correlation was noted for the heart and contralateral breast constraints when
comparing RP predicted and RP generated plan values. A regression analysis was also
performed for the RP generated plan versus the clinical plan value for the mean heart dose
(Figure 6). The R2 value resulted in 0.914 and p-testing further validated this correlation,
showing a p-value of 2.90E-19. From the scatterplot, a slope formula was generated from the
trend line which represents the relationship between the two variables (Figure 6). The resulting
formula was:
y = 1.1137x + 0.1217
The x variable corresponded to the RP generated plan values and the y variable
represented a predicted clinical plan value. This formula was then applied to the RP generated
plan values. The standard deviation was then found between the value created by the formula
and the clinical plan value which resulted in 48.6 cGy.
Clinical Testing
After completing the RP generated plans, a regression analysis was performed on all
recorded values. The analysis pinpointed the most correlated values as the RP generated plan
versus the clinical plan for the D 5 of the heart and for the mean heart dose. For both of these
factors, scatterplots were created and the R2 coefficients were found to be 0.9134 (Heart D 5 ) and
0.8811 (mean heart dose). These scatterplots can be found in Figures 7 and 8. Since the mean
heart dose is the most significant factor in choosing to DIBH over FB, the heart mean values
were analyzed further. From the scatterplot, a slope formula was generated as in the previous
step (Figure 8). The resulting formula was:
y = 1.0174x - 9.067
 10

This formula was then applied to the RP generated plan values and the standard deviation was
found between the value created by the formula and the clinical plan. This resulted in a standard
deviation of 27.2 cGy.
Discussion
The preliminary results from the model validation phase correspond to the results of
other researchers analyzing RapidPlan.13-18 This research showed that RP generated IMRT plans
with similar dosimetric outcomes to the clinical plans that were used for comparison. However,
because RP is a tool for IMRT optimization, this result was not necessarily expected since the
plans used in the creation of the model were planned with a 3D-CRT technique.
It was also found that with physician drawn PTVs, the RapidPlan generated plans were
able to accurately predict mean heart doses within 50 cGy and were therefore able to predict
which FB plans would have exceeded clinical acceptance values. This result indicated that there
is a link between the mean heart doses achieved with RP generated plans and the clinically
attempted 3D-CRT plan. However, this relationship was found by using target structures
contoured by the physician. Further evaluation was needed to find a link between a Test PTV
Eval contoured by the researchers and the mean heart doses that could be achieved clinically. As
a prediction method, physician contours would not be needed to determine which CT data set
would provide the optimal benefit for the patient.
Through clinical testing of the model, it was found that with a Test PTV Eval drawn by
the researchers, the RapidPlan generated plans were able to predict mean heart doses within 30
cGy. Therefore, the model created could be used to predict which patients would benefit from
DIBH without the need for the physician to contour target structures on multiple CT data sets.
With this result, the medical dosimetrist could import the FB CT data set into the TPS and
contour the heart, left lung, and a Test PTV Eval. Then, open fields could be placed for the Test
PTV Eval using the appropriate gantry and collimator angles. The model would be applied by
matching only the structures that were contoured and optimizing an IMRT plan to simulate a 3D-
CRT technique with field-in-field. With the mean heart value recorded from the RP generated
plan, it would be known that the generated value is close to what the clinical value would be if a
physician PTV were drawn. Medical Dosimetrist drawn PTV Evals would not be used for
clinical plan purposes, only in predicting which patients would benefit from DIBH. This practice
 11

would be beneficial to both physicians and medical dosimetrists by saving time in eliminating
the need to fully contour on multiple CT scans throughout the planning process.
Conclusion
In conclusion, RP can potentially be used as a predictor for mean heart doses in
determining the need for the DIBH technique with left-sided supine breast cancer patients. This
tool would save time in the planning process by eliminating the need to contour and create plans
on multiple CT scans. With physician drawn PTVs, the model created for this study proved to
be dependable in predicting mean heart doses within a standard deviation of 50 cGy. Further
clinical testing indicated that the model could accurately predict mean heart doses within a
standard deviation of 30 cGy when using Test PTV Evals that were contoured based on the
clinical reference wires.
One possible limitation of this study was the small sample size used when performing the
clinical test with Test PTV Evals drawn by the researchers. Since only 15 patients were tested, a
larger sample size during this step may have yielded more dependable results. Future research
with the model used for this study specifically should include testing the use of the model
prospectively. This testing could be completed by having the dosimetrist contour the heart, left
lung and a Test PTV Eval structure on each new patients FB data set. The medical dosimetrist
would then set beam angles, apply the RP model and record the RP generated plan value for the
mean heart dose. After receiving the physicians PTVs, the patient would be planned fully using
3D-CRT technique. The heart mean from these clinical plans would then be compared to the RP
generated plan values. This test would further evaluate the accuracy of the model in predicting
mean heart doses.
Centers that create their own RapidPlan model should do extensive testing and validation
of the model. Potential areas for caution include introducing new patients for prediction of mean
heart dose that show geometrical outliers from the model in use.
 12

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21. Wolmark N, Curran WJ, Momounas E, et al. RTOG 1304: A randomized phase III trial
evaluating post-mastectomy chestwall and regional nodal XRT and post-lumpectomy
regional nodal XRT in patients with positive axillary nodes before neoadjuvant
chemotherapy who convert to pathologically negative axillary nodes after neoadjuvant
chemotherapy. https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=1
304. Activated 2013.
22. Cranenbroek S, Van der sangen MJ, Kuijt GP, Voogd AC. Diagnosis, treatment and
prognosis of internal mammary lymph node recurrence in breast cancer patients. Breast
Cancer Res Treat. 2005;89(3):271-275. http://dx.doi.org/10.1007/s10549-005-2469-y.
 15

Figures

Figure 1. Example of patient setup lying supine on the breastboard from Qfix with the arms
positioned overhead.

Figure 2. Image showing positioning of the Vaclok bag under the left arm.
 16

Figure 3. Comparison of physicians PTV Eval in red and Test PTV Eval in blue.
 17

1600 Heart D5 300 Heart D35

1400
250
1200

Clinical (cGy)
Clinical (cGy)

1000 R = 0.8025 200

800 R = 0.8216
600 150
400 100
200
0 50
200 400 600 800 50 150 250
RapidPlan (cGy) RapidPlan (cGy)
350 Mean Heart Dose 40% V20 Lung
300 30%
Clinical (cGy)

250 R = 0.8206 R = 0.9789

Clinical
20%
200
150 10%

100 0%
100 200 300 0% 10% 20% 30% 40%
RapidPlan (cGy) RapidPlan
50% V10 Lung 80% V5 Lung
40%
R = 0.9788 60%
30%
Clinical

R = 0.9835
Clinical

20% 40%

10% 20%
0% 0%
0% 20% 40% 60% 0% 20% 40% 60%
RapidPlan RapidPlan

5% V3 Contralateral Breast
4%
3%
Clinical

2% R = 0.5781
1%
0%
0% 1% 2% 3%
RapidPlan

Figure 4. Scatter plots representing RP generated values against clinical generated values for the
constraints of interest for the 10 patients used for model verification.
 18

RapidPlan (cGy) 5000 Heart D5 500 Heart D35

4000 400

RapidPlan (cGy)
3000 300 R = 0.6613

2000 200
1000 R = 0.2849 100
0 0
0 1000 2000 3000 0 100 200 300
RapidPlan Prediction (cGy) RapidPlan Prediction (cGy)
1200 Mean Heart Dose 60% V20 Lung Dose
1000
RapidPlan (cGy)

50%

RapidPlan
800 40%
R = 0.06 R = 0.8916
600 30%
400 20%
200 10%
0 0%
0 200 400 600 800 1000 1200 0% 10% 20% 30% 40%
RapidPlan Prediction (cGy) RapidPlan Prediction
80% V10 Lung Dose 80% V5 Lung Dose

60% 60%
RapidPlan
RapidPlan

R = 0.8625
40% R = 0.8871 40%

20% 20%

0% 0%
0% 20% 40% 60% 0% 20% 40% 60%
RapidPlan Prediction RapidPlan Prediction
8% Contralateral Breast Dose

6%
RapidPlan

R = 0.7965
4%

2%

0%
0% 1% 2% 3%
RapidPlan Prediction

Figure 5. Scatter plots representing RP predictions against RP generated values for the
constraints of interest for 29 FB plans.
 19

1200
Mean Heart Dose
1000
Clinical (cGy)

800

600 y = 1.1137x + 0.1217

R = 0.9514
400

200

0
0 200 400 600 800 1000 1200
RapidPlan (cGy)

Figure 6. Scatter plot comparing RP plan and clinical plan values for the mean heart doses of 29
FB plans.

1800 Heart D5
1600

1400
y = 0.8758x + 27.836
1200 R = 0.9134
Clinical (cGy)

1000

800

600

400

200

0
0 500 1000 1500 2000
RapidPlan (cGy)

Figure 7. Scatter plot comparing RP plan and clinical plan values for D 5 of the heart.
 20

400 Mean Heart Dose

300
Clinical (cGy)

y = 1.0174x - 9.067
200 R = 0.8811

100

0
0 50 100 150 200 250 300
RapidPlan (cGy)

Figure 8. Scatter plot comparing RP plan and clinical plan values for the mean heart doses.
 21

Tables
Table 1. Table showing optimization objectives created for RapidPlan.

Target ID Objective Vol% Dose Priority

Yes PTV High Upper 0 103% 150
Yes PTV High Lower 100 100% 150
Yes PTV Low Upper 0 100% 125
Yes PTV Low Lower 95 90% 125
No Breast_R Upper (fixed dose, Generated 300 cGy Generated
generated vol)
No Heart Upper (fixed dose, Generated 2500 cGy Generated
generated vol)
No Heart Upper (fixed vol, 35 Generated Generated
generated dose)
No Heart Upper (fixed vol, 5 Generated Generated
generated dose)
No Heart Mean N/A Generated Generated
No Heart Line Generated Generated Generated
No Lung_L Upper (fixed dose, Generated Generated Generated
generated vol)
No Lung_R Upper (fixed dose, Generated 500 cGy Generated
generated vol)

Table 2. Summary of model training results.

Structure Trained R2 X2 Matched In-Field Suggested Outliers
Breast_R Yes 0.466 1.131 88 45 54 2
Heart Yes 0.867 1.027 86 81 24
Lung_L Yes 0.929 1.099 91 91 38
Lung_R N/A 0.7 1.096 89 51 14
PTV_High N/A 262
PTV_Low Yes 46
Sternum Yes 0.869 1.138 89 74 1
Thyroid Yes 0.95 1.227 79 47 54 7