Quantified VMAT plan complexity in relation to measurement-based quality assurance results

Volumetric-modulated arc therapy (VMAT) treatment plans that are highly modulated or complex may result in disagreements between the planned dose distribution and the measured dose distribution. This study investigated established VMAT complexity metrics as a means of predicting phantom-based measurement results for 93 treatments delivered on a TrueBeam linac, and 91 treatments delivered on two TrueBeam STx linacs. Complexity metrics investigated showed weak correlations to gamma passing rate, with the exception of the Modulation Complexity Score for VMAT, yielding moderate correlations. The Spearman's rho values for this metric were 0.502 (P < 0.001) and 0.528 (P < 0.001) for the TrueBeam and TrueBeam STx, respectively. Receiver operating characteristic analysis was also performed. The aperture irregularity on the TrueBeam achieved a 53% true positive rate and a 9% false-positive rate to correctly identify complex plans. Similarly, the average field width on the TrueBeam STx achieved a 60% true-positive rate and an 8% false-positive rate. If incorporated into clinical workflow, these thresholds can identify highly modulated plans and reduce the number of dose verification measurements required.