Obstacles and advances in intensity-modulated radiation therapy treatment planning

In this paper, the current state of intensity-modulated radiation therapy (IMRT) treatment planning systems is reviewed, including some inefficiencies along with useful workarounds and potential advances. Common obstacles in IMRT treatment planning are discussed, including problems due to the lack of scatter tails in optimization dose calculations, unexpected hot spots appearing in uncontoured regions, and uncontrolled tradeoffs inherent in conventional systems. Workarounds that can be applied in current systems are reviewed, including the incorporation of an 'anchor zone' around the target volume (including a margin of separation), which typically induces adequate dose falloff around the target, and the use of pseudostructures to reduce conflicts among objective functions. We propose changing the planning problem statement so that different dosimetric or outcome goals are prioritized as part of the prescription ('prioritized prescription optimization'). Higher-priority goals are turned into constraints for iterations that consider lower-priority goals. This would control tradeoffs between dosimetric objectives. A plan review tool is proposed that specifically summarizes distances from a structure to hot or cold doses ('dose-distance plots'). An algorithm for including scatter in the optimization process is also discussed. Lastly, brief comments are made about the ongoing effort to use outcome models to rank or optimize treatment plans.