Photon optimizer (PO) vs progressive resolution optimizer (PRO): a conformality- and complexity-based comparison for intensity-modulated arc therapy plans

This study aimed to provide guidance on the advantages and limitations of a new optimizer, "photon optimizer" (PO), when compared with its predecessor, "progressive resolution optimizer" (PRO), for intensity-modulated arc therapy (IMAT) plans. Eleven study plans that included a cohort of prostate, head and neck, and brain treatment sites were optimized using both PRO and PO algorithms. A plan template using the same objectives for the same number of iterations was used for each optimized plan to obtain hypothetical treatment plans that would be comparable with a clinical plan. Analysis was performed using plan conformity-based parameters such as target volume coverage factor, conformation number and homogeneity indices, and plan complexity assessment parameters such as small aperture score, modulation indices, and monitor unit variation with arc angle for prostate, brain and head, and neck IMAT treatment plans. Plan conformality analysis demonstrated that conformation numbers, target volume coverage factors, and homogeneity indices produced by the 2 optimizers were comparable for most anatomic sites. IMAT treatment plans produced using the PRO optimizer were found to be less complex than plans produced using the PO optimizer, in terms of multileaf collimator (MLC) leaf position variability and modulation complexity scores. Similarly, the PRO optimizer was shown to produce treatment plans that used fewer monitor units (and generally fewer monitor unit per degree of arc rotation) than PO optimizer. This study demonstrated that the PO optimizer can produce IMAT treatment plans with a similar degree of dose conformity to the target volume and generally improved organ at risk sparing, compared with the PRO optimizer. Better coverage to organs at risk produced by plans optimized using PO was observed to have higher MLC variability and monitor units. Therefore, careful evaluation of treatment plan conformity and complexity before assessing its deliverability is recommended when implementing the routine use of PO optimizer.