Development of an autonomous treatment planning strategy for radiation

therapy with effective use of population-based prior data

Huan Wang, Peng Dong, Hongcheng Liu, and Lei Xinga)
Department of Radiation Oncology, Stanford University, Stanford, CA 94305-5847, USA
(Received 26 June 2016; revised 28 October 2016; accepted for publication 2 December 2016;
published 30 January 2017)
Purpose: Current treatment planning remains a costly and labor intensive procedure and requires
multiple trial-and-error adjustments of system parameters such as the weighting factors and prescrip-
tions. The purpose of this work is to develop an autonomous treatment planning strategy with effec-
tive use of prior knowledge and in a clinically realistic treatment planning platform to facilitate
radiation therapy workflow.
Method: Our technique consists of three major components: (i) a clinical treatment planning system
(TPS); (ii) a formulation of decision-function constructed using an assemble of prior treatment plans;
(iii) a plan evaluator or decision-function and an outer-loop optimization independent of the clinical
TPS to assess the TPS-generated plan and to drive the search toward a solution optimizing the deci-
sion-function. Microsoft (MS) Visual Studio Coded UI is applied to record some common planner-
TPS interactions as subroutines for querying and interacting with the TPS. These subroutines are
called back in the outer-loop optimization program to navigate the plan selection process through the
solution space iteratively. The utility of the approach is demonstrated by using clinical prostate and
head-and-neck cases.
Results: An autonomous treatment planning technique with effective use of an assemble of prior treat-
ment plans is developed to automatically maneuver the clinical treatment planning process in the plat-
form of a commercial TPS. The process mimics the decision-making process of a human planner and
provides a clinically sensible treatment plan automatically, thus reducing/eliminating the tedious manual
trial-and-errors of treatment planning. It is found that the prostate and head-and-neck treatment plans
generated using the approach compare favorably with that used for the patients actual treatments.
Conclusions: Clinical inverse treatment planning process can be automated effectively with the
guidance of an assemble of prior treatment plans. The approach has the potential to significantly
improve the radiation therapy workflow. 2016 American Association of Physicists in Medicine
[https://doi.org/10.1002/mp.12058]

Key words: dose optimization, IMRT, inverse planning, treatment planning, VMAT

1. INTRODUCTION There have been intense research activities in treatment

Inverse planning derives a patient-specific treatment plan
through iterative interactions with an objective function,
whose role is to mathematically rank a candidate treatment
plan. While the approach has led to clinical implementa-
tion of IMRT and VMAT, the planning process routinely
used in the clinics is rather tedious and labor intensive.
The underlying issue responsible for this problem is the
involvement of multiple model parameters (e.g., the
weighting factors and prescription in the objective func-
tion) in treatment planning.14 Ideally, these model param-
eters should be optimized before or together with the
fluence map or machine parameters such as the apertures
defined by multileaf collimators.5,6 For computational pur-
pose, these parameters are generally determined through
manual trial-and-errors since their influence on the final
dose distribution is not known until an optimization is
done. Consequently, treatment planning remains to be one
of the most labor intensive and time-consuming tasks in
current radiation therapy practice.
planning automation to improve the plan quality and work-
flow. Xing et al. pioneered the automation of the manual
selection process of model parameters two decades ago with
the use of a plan evaluation function and outer-loop optimiza-
tion.1,2 Recently, it is attempted to replace the original deci-
sion-function constructed based on empirically known DVHs
or clinical experience by a prior treatment plan, which had
similar anatomy to the one under planning.4 In reality, how-
ever, no two cases are identical and the use of DVHs of a pre-
vious patient as reference for guiding the plan selection could
lead to sub-optimal solution. Here, we propose to consider a
spectrum of historical plans that share similar anatomical fea-
tures in carrying out the two-loop optimization. With effec-
tive use of an assemble of prior treatment plans, the resultant
solution out of the two-loop optimization is no longer tight-
ened up to a single reference plan, thus making it possible to
find better dosimetric distribution.
In practice, other options for utilizing historical treatment
plans are through the use of class-solution7,8 and machine
learning techniques, in which a library of prior plans are

389 Med. Phys. 44 (2), February 2017 0094-2405/2017/44(2)/389/8 2016 American Association of Physicists in Medicine 389
390 Wang et al.: Autonomous treatment planning
employed to train the system to provide the best model
parameters. The parameters are then used as input of subse-
quent inverse planning. The method has recently been applied
to predict the weighting factors911 and the prescription
DVHs1215 needed for driving an inverse planning calcula-
tion. We emphasize that all these approaches only use prior
knowledge-derived parameters (i.e., either weighting or pre-
scription or both) to warm start the inverse planning,
instead of using them to guide the plan search throughout the
optimization process. Additionally, the predicted DVHs pre-
scription by machine learning may not always be physically
realizable. For completeness, we mention that heuristic opti-
mization14,1621 and multiobjective optimization2224 have
also been developed to facilitate inverse planning process and
these algorithms can, in principle, be improved with incorpo-
ration of prior knowledge, especially population-based data.
The purpose of this work is to develop an autonomous
treatment planning technique with effective use of a spectrum
of prior plans that share similar anatomical features with the
case under planning. Instead of using a simplified research
inverse planning platform,2528 which often ignores some
important geometric and physical factors, we proceed with an
API-like programming environment capable of interacting
FIG. 1. Flowchart of the autopiloted plan optimization scheme. An outer-loop decision-function analyzes the TPS plan and feeds the TPS optimizer with updated
parameters for iterative improvement of the treatment plan. The algorithm terminates if either (i) ck = 0, or (ii) no improvement has been made in consecutive
iterations. [Color figure can be viewed at wileyonlinelibrary.com]
Medical Physics, 44 (2), February 2017
390
with a commercial treatment planning system (TPS) to imple-
ment the proposed strategy that mimics a planners interac-
tive planning and decision-making process in searching for a
sensible solution. The approach here enables us to leverage
the sophisticated software subroutines (e.g., dose calculation,
optimization, image registration, etc.) existing already in a
clinical-grade TPS to test the new algorithm. By implement-
ing the outer-loop optimization strategy in this programming
environment, we demonstrate that IMRT/VMAT treatment
planning can be readily automated.
2. METHODS AND MATERIALS
Our treatment planning system consisted of following
components: (i) a clinical TPS; (ii) a robust formulation of
plan evaluator or decision-function; (iii) an outer-loop opti-
mization independent of the clinical TPS to assess a TPS-
generated plan and to drive the search toward a solution con-
sistent with the decision-function; and (iv) a programming
method to query and interact with the TPS using Microsoft
(MS) Visual Studio Coded UI, which is applied to record
some common planner-TPS interactions as subroutines. The
following summarizes the details of the technique.
391 Wang et al.: Autonomous treatment planning
2.A. Software platform for autopiloted planning
Figure 1 shows the workflow of the population knowl-
edge-based autonomous planning. An independent C# pro-
gram is written to accomplish the tasks delineated in
Fig. 1. In this program, the interactions with a commercial
Eclipse TPS (Varian Medical Systems, Palo Alto, CA) are
realized through a series of subroutines that are prere-
corded actions of a planner in operating the TPS by using
Microsoft Visual Studio Coded UI.29,30 For example, to
perform a 3D dose calculation in Eclipse, F5 is clicked
after the beam setup is done. A subroutine for performing
dose calculation can be generated by recording this action,
which is called when dose distribution needs to be
updated in the C# program. Coded UI provides a unique
framework for us to probe and manipulate UI elements of
TPS in application programming in C# or other program-
ming environment. We have recorded more than a dozen
essential actions in Eclipse operation for the work here
(for example, exporting DVH to a file by pulling down
the textbox show DVH view and selecting export DVH the following bi-level optimization problem:
in tabular form, opening an optimization window by
clicking F10 and then starting an optimization by click-
ing Optimize button, and converting an isodose curve
into a structure by right clicking dose on the left side
menu and then selecting convert isodose level to struc-
ture) and saved them into a library of subroutines. The
subroutines are called into our C# program to interact with
the TPS for a variety of actions, for example, to assess the
quality of a plan generated by the TPS and to provide
updated model parameters to refine the Eclipse plan. We
note that the method described here is not limited to the
Eclipse TPS and this will be discussed in Section 4.
2.B. Automation of VMAT/IMRT treatment planning
2.B.1. Library of reference cases
For a given patient, a set of reference plans with simi-
lar anatomy is chosen automatically with some predefined
geometric criteria.21 Specifically, the images of current
case are overlaid with a candidate reference plan from a
library of previously treated patients and the correlation
between the two sets of images is examined. Only the ref-
erence cases with high correlation are selected as reference
plans. For each structure, the signed difference of the con-
tour points of the current and reference plans is computed
for ray lines starting from the center of the mass of the
structure.31 The points for a ray-line to be in and out of
the structure are recorded. The signed difference of an
intercepting point is given by subtracting the radial dis-
tance of the point in the current case from that of the ref-
erence case. A plan is not considered as a good reference
if the signed difference of any intercepting point in any
structure is greater than 3 mm for a small structure such
as the optic nerve and 515 mm for a large structure such
as the skin contour.
Medical Physics, 44 (2), February 2017
391
2.B.2. Autopilot process
The iterative adjustment of Eclipse plan follows the flow-
chart delineated in Fig. 1, which involves the following key
steps: (i) obtaining a candidate Eclipse plan, (ii) evaluating
the Eclipse plan with the independent plan evaluator or deci-
sion-function, (iii) deriving a new set of Eclipse planning
with the new parameters, and (iv) updating the Eclipse plan-
ning parameters and obtaining the corresponding Eclipse
plan. Specifically, at each step during the iterative adjustment
of TPS planning parameters, the distance of the DVH curves
of the involved structures to the DVHs of the best plan in the
ensemble is examined. For the structure with the largest dis-
tance, a trial adjustment of the Eclipse plan is made by chang-
ing the weighting of the structure and reoptimization of the
Eclipse plan. This continues until no further improvement in
the DVHs with the above adjustment is noted. Using an
ensemble of reference plans allows us to minimizing any
potential overfitting problem caused by the use of a single
reference plan. Formally, the plan selection process is to solve
min c
s:t:
8 !
> x 2 arg minfFTPS x; w : x 2 XTPS wg
>
< refl
Cr;j $ Cr;j x! % c; 8r; j
refh (1)
>
> Cr;j x! $ Cr;j % c; 8r; j
:
c&0
where w is the input parameter to the TPS, FTPS x; w and
XTPS w are the objective function and the feasible region of
the optimization problem solved by the TPS for fixed param-
eter w, Cr;j x! is the j-th dosimetric characteristic variable of
structure r for the plan x! , and c measures the infeasibility of
the constraint that Cr;j x! should fall within the band
h i
refl refh refl refh
Cr;j ; Cr;j . The values of Crj and Crj represent the low
and high boundary values of the same dosimetric characteris-
tic variable extracted from the library of reference plans. In
this study, we divide the DVH curve of each structure into
segments and the j-th dosimetric characteristic variable of
structure r is simply the j-th DVH segment of the structure.
Note that the prior knowledge or the library of reference plans
sets our preferred variation range of the dosmetric quantity
Crj , which is similar to the use of prior data to set expecta-
tions for the planning process in previous studies.1215,18,19
Also note that the first constraint in (1) requires that plan x!
should be the output of the optimization problem in the TPS,
which serves as a lower level minimization problem embed-
ded within the bi-level model framework.
Our approach of utilizing prior plans goes, however,
beyond merely setting expectations as the knowledge is inte-
grated with the optimization algorithm to guide the search for
the optimal solution. In order to speed up the calculation, the
beam and weighting parameters of a prior plan in the middle
of the ensemble are used to warm start the autopiloted
392 Wang et al.: Autonomous treatment planning
planning process. However, the final solution does not rely
on the selection of the initial selection of starting plan. Dur-
ing the calculation, instead of letting the DVH segment value
Crj stop anywhere when its value is inside the range defined
by Crjrefl refh
and Crj , we continuously push the Crj ref
value
toward a lower value in the predefined range by changing the
reference value.
2.C. Evaluation
The above technique is applied to plan two clinical
cases: a five-field IMRT prostate case and a VMAT
head-and-neck (HN) case. In the prostate IMRT case,
6 MV photon energy is used and the beam angles are
0o, 50o, 100o, 260o, and 310o, respectively. 78 Gy is pre-
scribed to cover V95 of the PTV in 39 fractions. For
comparison, the resultant dose distributions of the autopi-
lot scheme are compared with the corresponding plans
used for clinical treatments. To construction of the refer-
ence plan library, 15 previously treated prostate cancer
patients are selected using the procedure outlined in Sec-
tion 2.B. For the HN case, two 360o 6 MV VMAT arcs
are used. Nine previously treated HN cases are selected
as reference plans. We acknowledge that the database can
be enlarged to better cover the variations in patient anat-
omy. Given that the cases selected to form the library
are reasonably close to the cases under planning and
FIG. 2. Plots of reference DVHs of bladder (a), rectum (b), and PTV (c) for the prostate case under planning. The ensemble of DVHs represents the preferred
range of the resultant DVH curve.
FIG. 3. DVHs of the bladder, rectum, and prostate at iteration #1 (dotted), #7 (dashed), and #14 (solid). A systematic improvement in the DVHs is observed.
Medical Physics, 44 (2), February 2017
392
considering the pilot nature of the study, the number is
reasonable.
3. RESULTS
3.A. Five-eld IMRT prostate treatment
In Fig. 2, we show the band of DVH representing the pre-
ferred range and distribution of the resultant DVH curve for
the prostate case under planning. To illustrate the progressive
improvement of the autopilot process, in Fig. 3 we show the
DVH results of involved structures for the 1st, 7th, and 14th
iteration. The improvement saturate after about 14 iterations
and the calculation thus terminates after the 14th iteration. At
each outer-loop iteration, the TPS parameters are adjusted,
which leads to a different dose distribution. While these plans
are on the Pareto front, the autoplanning process here
explores plans beyond the traditional Pareto front. For exam-
ple, when a hot spot presents in PTV, a tuning structure
would be created automatically by converting the correspond-
ing isodose curve into a structure and this process would
drive the plan away from the traditional Pareto surface, lead-
ing to improvements in all DVHs. Figure 4 shows the DVH
comparison between the clinical and autopiloted plans for the
case. Figure 5 shows the isodose distribution of the two
plans. Only minor discrepancy is seen between the autopi-
loted plan obtained under the guidance of the population-
393 Wang et al.: Autonomous treatment planning 393

based library of reference plans and clinical plan generated
by a human planner independently.
3.B. HN VMAT case
In Fig. 6, we show the ensemble of DVHs of the spinal
cord, brainstem and PTV of the reference plans obtained
using the method of Section 2.B for the HN case under plan-
ning. Figure 7 shows the DVH comparison between the clini-
cal and autopiloted planning for the case, and Fig. 8 shows
the isodose distributions of the two plans. Again, only minor
discrepancy is seen between the autopiloted plan obtained
under the guidance of the population-based library of refer-
ence plans and clinical plan generated by a human planner
independently.
Computationally, depending on the complexity of the
case, it takes about a few hours to complete a plan selection
process, but this can be improved with improved program-
ming, and, in the future, better integration with the commer-
cial TPS. However, comparing with the current manual
planning process, which could take days of a dosimetrists
time for clinically challenging cases, the proposed method

FIG. 4. A comparison of DVHs of the clinical and autopiloted plans for the five-field IMRT prostate case. The dashed and solid curves represent the DVHs of
clinical and autopiloted plans, respectively.

FIG. 5. Side-by-side comparison of the isodose distributions of autopiloted (right) and clinical (left) plans for the prostate case. [Color figure can be viewed at
wileyonlinelibrary.com]

FIG. 6. Plots of reference DVH curves of spinal cord (a), brainstem (b), and PTV (c) for the head-and-neck case under planning. The ensemble of DVHs presents
the preferred range of the resultant DVH curve.

Medical Physics, 44 (2), February 2017

394 Wang et al.: Autonomous treatment planning 394

eliminates the manual trial-and-error modification of the opti-
mization parameters and facilitates the clinical workflow.
4. DISCUSSION
In inverse planning, an optimized solution is obtained
under the guidance of an objective function containing
multiple model parameters.1,10,27,3235 In the past two dec-
ades, much of the efforts in research and commercial product
development have been focused on finding a better function
with mathematical constraints to provide clinically sensible
solution. While the formulation of objective function and the
technique used to search through the solution space under the
guidance of the objective function are important to the

FIG. 7. A comparison of DVHs of the clinical and autopiloted plans for the two-arc head and neck VMAT case. The dashed and solid curves represent the DVHs
of clinical and autopiloted plans, respectively.

FIG. 8. Side-by-side comparison of the isodose distributions of autopiloted (right) and clinical (left) plans for the head-and-neck case. [Color figure can be
viewed at wileyonlinelibrary.com]

Medical Physics, 44 (2), February 2017

395 Wang et al.: Autonomous treatment planning
success of inverse planning, clinical IMRT/VMAT planning
has been handicapped by the involvement of multiple model
parameters that necessitates trial-and-error determination. In
this paper, we proposed an effective technique to autopilot
the VMAT/IMRT planning process in a clinical TPS plat-
form. The automation is realized by combining the function-
alities of the black-box TPS and a decision-function
incorporating population-based prior knowledge. The calcu-
lation is analogous to the planning process of a human plan-
ner, with a candidate plan assessed iteratively by the
decision-function each time after the Eclipse optimization is
done.1,2,10 During the autopiloted planning, the C# program
interacts with TPS continuously to extract the updated infor-
mation and to instruct on what to do next until a satisfactory
plan is obtained.
In addition to the effective utilization of population-based
prior data, a technical innovation of the work here is the use
of Coded UI to recording the mouse clicks/keystrokes as exe-
cutable subroutines for specific tasks during planning. By
doing so, we can extract the updated information of treatment
planning and interact with the TPS effectively to autopilot the
process. In practice, because the Windows platform encom-
passes a large number of TPS and other clinical application
software, the presented method should be valuable for future
clinical research and practice. We note that, while Coded UI
is designed for the Windows environment, the principles and
strategies proposed here are quite broad. There are analogous
software tools for other operating systems. For Unix and
Linux environment, other record-and-playback services such
as UNIX Session Recorder (Sikuli, Linux Desktop Testing
Project) can be employed.36
The programming environment described here is highly
interactive, making it easy to principle-testing and prototyp-
ing. Currently, the development of treatment planning algo-
rithm(s) is often done in simplified software platforms2528
without considering some important geometric and physical
factors. The approach here enables researchers to leverage the
sophisticated software subroutines existing already in a clini-
cal-grade TPS to test new ideas without repeating some well-
known tasks. The approach may also facilitate the translation
of research to clinical practice. Finally, we note that the
implementation here represents only one of many possible
applications of the proposed strategy. The approach is appli-
cable to streamline other clinical tasks in TPS or other soft-
ware tools. We also note that practical issues such as error
handling, such as unexpected windows popup during the
autopiloted planning process, are not discussed. In principle,
a preventive action can be taken by adding some checking
points in the C# program of autopiloted planning to monitor
the potential popup window(s).
CONCLUSION
Inverse planning in modern radiation therapy involves
multiple steps of manual operation and is known to be a
time-consuming process. In this work, we propose an
autonomous treatment planning strategy to facilitate the
Medical Physics, 44 (2), February 2017
395
inverse planning process. The research here is directly
translatable to clinical practice as the backbone of the plan
optimization is built upon a commercial TPS. Additionally,
the approach is quite general and allows us to incorporate
empirical judgment and population-based prior knowledge
into the plan selection process. The utility of the approach
has been demonstrated successfully by using two clinical
cases. With the increased interest in using prior knowledge
in radiation oncology applications, the data analytics and
decision-making method may prove to be useful to facili-
tate clinical workflow.
ACKNOWLEDGMENTS
This work is partially supported by NIH (5R01
CA176553) and Varian Medical Systems.
CONFLICT OF INTEREST
Lei Xing is the principal investigator of a master research
agreement (MRA) with Varian Medical Systems.
a)
Author to whom correspondence should be addressed. Electronic mail:
lei@stanford.edu.
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