Photon Optimizer (PO) prevails over Progressive Resolution Optimizer (PRO) for VMAT planning with or without...

The enhanced dosimetric performance of knowledge-based volumetric modulated arc therapy (VMAT) planning might be jointly contributed by the patient-specific optimization objectives, as estimated by the RapidPlan model, and by the potentially improved Photon Optimizer (PO) algorithm than the previous Progressive Resolution Optimizer (PRO) engine. As PO is mandatory for RapidPlan estimation but optional for conventional manual planning, appreciating the two optimizers may provide practical guidelines for the algorithm selection because knowledge-based planning may not replace the current method completely in a short run. Using a previously validated dose-volume histogram (DVH) estimation model which can produce clinically acceptable plans automatically for rectal cancer patients without interactive manual adjustment, this study reoptimized 30 historically approved plans (referred as clinical plans that were created manually with PRO) with RapidPlan solution (PO plans). Then the PRO algorithm was utilized to optimize the plans again using the same dose-volume constraints as PO plans, where the line objectives were converted as a series of point objectives automatically (PRO plans). On the basis of comparable target dose coverage, the combined applications of new objectives and PO algorithm have significantly reduced the organs-at-risk (OAR) exposure by 23.49-32.72% than the clinical plans. These discrepancies have been largely preserved after substituting PRO for PO, indicating the dosimetric improvements were mostly attributable to the refined objectives. Therefore, Eclipse users of earlier versions may instantly benefit from adopting the model-generated objectives from other RapidPlan-equipped centers, even with PRO algorithm. However, the additional contribution made by the PO relative to PRO accounted for 1.54-3.74%, suggesting PO should be selected with priority whenever available, with or without RapidPlan solution as a purchasable package. Significantly increased monitor units were associated with the model-generated objectives but independent from the optimizers, indicating higher modulation in these plans. As a summary, PO prevails over PRO algorithm for VMAT planning with or without knowledge-based technique.