Automated Radiotherapy Planning for Head-and-neck Cancer: Multi-institutional Development, Validation, and Clinical...

The purpose of this study was to develop, validate, and clinically implement a standardized automated treatment planning framework using Monaco scripting and to evaluate its dosimetric performance, consistency, and organ-at-risk (OAR) sparing compared with conventional manual planning for head-and-neck cancer (HNC) across a multi-institutional network.

A Pareto-based multi-criteria optimization template was iteratively developed, validated on >300 retrospective cases, and implemented across 14 centers. Forty-seven HNC patients were replanned using clinically approved plan (CA), AutoPlan (AP), and AutoPlan iteration (API) approaches and categorized into single-target (n = 11), two-target (n = 35), and three-target (n = 1) cohorts. Plan quality was analyzed in ProKnow using scorecard evaluation, boxplots, histograms, and scatter-plot correlations focusing on target coverage and doses to critical organs including brainstem, spinal cord, and bilateral parotids.

Automated workflows demonstrated superior consistency and OAR sparing compared with CA plans. AP achieved the highest overall scorecard performance, while API consistently produced the most stable dose distributions with lower variability and weaker correlations between PTV_High coverage and OAR doses. CA plans exhibited the widest dose variability and stronger OAR dose dependence. Clinically, the automated scripts achieved >70% automation and have been used in over 850 patients with minimal manual intervention.

Automated Monaco scripting significantly improves plan quality, consistency, and OAR sparing in HNC radiotherapy, supporting routine clinical adoption - particularly of iterative API workflows - for standardized multi-center practice.