Iranian Journal of Medical Physics

Iranian Journal of Medical Physics

Dosimetric Comparison of Volumetric Modulated Arc Therapy Treatment Plans using Pareto and Constrained Modes of Optimization with Monaco Treatment Planning System for Left Breast Cancer with Breast Conserving Surgery

Document Type : Original Paper

Authors
FIZA MOHAMMED ASLAM SYED 1
Shreekripa Rao 2
RECHAL NISHA DSOUZA 1
Srinidhi Gururajarao Chandraguthi 3
Krishna Sharan 4
Shirley Salins 5
1 Medical Radiation Physics Programme, Department of Radiation Oncology, Manipal College of Health Professions, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India- 576104.
2 Radiotherapy and Oncology Assistant Professor in Medical Physics School of Allied Health Sciences Kasturba Medical College Manipal Academy of Higher Education Manipal 576104
3 Radiotherapy and Oncology Senior Grade Lecturer Medical Physics Kasturba Medical College Manipal Academy of Higher Education Manipal India
4 KSHEMA, NITTE, MANGALORE
5 Associate Professor, Department of Radiotherapy & Oncology, Kasturba Medical College, Manipal
10.22038/ijmp.2025.78932.2396
Abstract
Introduction: Volumetric Modulated Arc Therapy (VMAT) is an advanced method of radiation therapy with increased flexibility in intensity modulation. The study aims to compare the dosimetric outcomes of VMAT treatment plans generated using Pareto and Constrained modes of optimization for left breast cancer with breast-conserving surgery (BCS). 
Material and Methods: We carried out a retrospective study of twenty female patients who underwent BCS for left breast cancer. VMAT treatment plans were generated using two optimization modes, Pareto and Constrained, on the Monaco (version 5.11.03) treatment planning system (TPS), with a single arc of 6MV x-ray photon beam from Elekta Versa HD linear accelerator (linac). The prescribed dose was 42.56 Gray (Gy) in 16 fractions to the PTV. Dosimetric parameters, such as the target volume coverage, organs at risk (OARs) doses, homogeneity index (HI), as well as conformity index (CI), were studied and compared between the two modes of optimization using the Wilcoxon signed-rank test (Jamovi 2.3.26). 
Results: The study showed that the Pareto mode of optimization within VMAT gave superior outcomes, with increased coverage of the target and comparable OAR doses. However, there is a slight increase in the volume receiving 107% of the prescribed dose (V107), maximum dose (Dmax) within the target volume, and monitor units (MU); the HI and CI show excellent performance. 
Conclusion: This study suggests that Pareto mode optimization in VMAT is a preferable and superior approach for left breast cancer patients undergoing BCS.
Keywords
Pareto Constrained Breast
Conserving Surgery Volumetric Modulated Arc Therapy
Subjects
  1. Feng Y, Spezia M, Huang S, Yuan C, Zeng Z, Zhang L, et al.. Breast cancer development and progression: Risk factors, cancer stem cells, signaling pathways, genomics, and molecular pathogenesis. Genes Dis. 2018 May 12;5(2):77-106.
  2. Mattiuzzi C, Lippi G. Current Cancer Epidemiology. J Epidemiol Glob Health. 2019 Dec;9(4):217-222.
  3. Ansari, M. Shahanawaj, Khan, M. Ziyauddin, Sharma, S. Dutt, Yadav, N., Zope, M. Kumar, et al. Analysis of Dose-Distribution in Left-Lung and Heart as Increasing the Number of Beams in Left-Sided Breast Irradiation. Iranian Journal of Medical Physics, 2024; 21(1): 1-7.
  4. Zucca-Matthes G, Urban C, Vallejo A. Anatomy of the nipple and breast ducts. Gland Surg. 2016 Feb;5(1):32-6.
  5. Sree SV, Ng EY, Acharya RU, Faust O. Breast imaging: A survey. World J Clin Oncol. 2011 Apr 10;2(4):171-8.
  6. Wang L. Early Diagnosis of Breast Cancer. Sensors (Basel). 2017 Jul 5;17(7):1572.
  7. Farhood, B., Mahdavi, S. R., Emranpour, M. H., Mohammadi Asl, K., Nekoui, N., Knaup, C. et al. Skin Reaction in Radiation Therapy for Breast Cancer. Iranian Journal of Medical Physics, 2014; 11(4): 316-321.
  8. Burguin A, Diorio C, Durocher F. Breast Cancer Treatments: Updates and New Challenges. J Pers Med. 2021 Aug 19;11(8):808.
  9. Zeinali Rafsanjani, B., Mosleh-Shirazi, M. A., Faghihi, R., Mosalaei, A., Omidvari, S., Hadad, K., et al. Breast Cancer and its Radiotherapeutic Methods. Iranian Journal of Medical Physics, 2012; 9(2): 75-85.
  10. Koka K, Verma A, Dwarakanath BS, Papineni RVL. Technological Advancements in External Beam Radiation Therapy (EBRT): An Indispensable Tool for Cancer Treatment. Cancer Manag Res. 2022 Apr 11;14:1421-1429.
  11. Das Majumdar SK, Amritt A, Dhar SS, Barik S, Beura SS, Mishra T, et al.. A Dosimetric Study Comparing 3D-CRT vs. IMRT vs. VMAT in Left-Sided Breast Cancer Patients After Mastectomy at a Tertiary Care Centre in Eastern India. Cureus. 2022 Mar 28;14(3):e23568.
  12. Ahmad A, Das S, Kharade V, Gupta M, Pandey VP, K V A, et al.. Dosimetric Study Comparing 3D Conformal Radiotherapy (3D-CRT), Intensity Modulated Radiotherapy (IMRT) and Volumetric Modulated Arc Therapy (VMAT) in Hypofractionated One-Week Radiotherapy Regimen in Breast Cancer. Cureus. 2022 Nov 24;14(11):e31860.
  13. Chang JS, Chang JH, Kim N, Kim YB, Shin KH, Kim K, et al. Intensity Modulated Radiotherapy and Volumetric Modulated Arc Therapy in the Treatment of Breast Cancer: An Updated Review. J Breast Cancer. 2022 Oct;25(5):349-365.
  14. Balaji K, Subramanian B, Yadav P, Anu Radha C, Ramasubramanian V. Radiation therapy for breast cancer: Literature review. Med Dosim. 2016 Autumn;41(3):253-7.
  15. Quan EM, Li X, Li Y, Wang X, Kudchadker RJ, Johnson JL, et al.. A comprehensive comparison of IMRT and VMAT plan quality for prostate cancer treatment. Int J Radiat Oncol Biol Phys. 2012 Jul 15;83(4):1169-78.
  16. Sun H, Wang N, Huang G, Liu X. Dosimetric comparison of fixed field dynamic IMRT and VMAT techniques in simultaneous integrated boost radiotherapy of prostate cancer. Medicine (Baltimore). 2022 Dec 16;101(50):e32063.
  17. Ghaznavi H, Jafari A. Risk of Heart Disease in Left-Sided Breast Cancer Radiotherapy: With Considering Baseline Risk of Heart Diseases. Iran J Med Phys 2022; 19: 275-281.
  18. Sharma, D., Marjara, N., Goel, V., Loganathan, N. Dosimetric Study of Voluntary Deep Inspiratory Breath-Hold (V-DIBH) Vs Free Breathing (FB) Technique on Organ Doses for Left-Sided Breast Cancer. Iranian Journal of Medical Physics, 2022; 19(6): 329-333.
  19. Adeneye S, Akpochafor M, Adedewe N, Habeebu M, Jubril R, Adebayo A, et al.. A Dosimetric Comparison of Volumetric Modulated Arc Therapy and Intensity Modulated Radiotherapy in Patients Treated with Post-Mastectomy Radiotherapy. Eur J Breast Health. 2023 Jan 1;19(1):92-98.
  20.  
  21. Rashid A, Ahmad Z, Memon MA, Hashim ASM. Volumetric Modulated Arc Therapy (VMAT): A modern radiotherapy technique - A single institutional experience. Pak J Med Sci. 2021 Mar-Apr;37(2):355-361.
  22.  
  23. Kodama T, Kudo S, Hatanaka S, Hariu M, Shimbo M, Takahashi T, et al. Algorithm for an automatic treatment planning system using a single-arc VMAT for prostate cancer. J Appl Clin Med Phys. 2021 Dec;22(12):27-36.
  24. Clements M, Schupp N, Tattersall M, Brown A, Larson R. Monaco treatment planning system tools and optimization processes. Med Dosim. 2018 Summer;43(2):106-117.
  25. White, J., Tai, A., Arthur, D., Buchholz, T., Macdonald, S., Marks, L., et al. (2009) Breast Cancer Atlas for Radiation Therapy Planning: Consensus Definitions Collaborators. Breast Cancer Atlas for Radiation Therapy Planning, 73, 944-951.
  26. Attallah H, Hamed R, Abdelkader H, Abdallah M, Mahmoud A, Haggag I, et al. Radiotherapy to the left breast with 3DCRT, IMRT or VMAT: International Medical Center experience. J Cancer Ther. 2021;12(2):107–115.
  27. Dsouza RN, Sharan K, Sukumar S, Chandraguthi SG, Rao S, Lewis S, et al.  Comparison of treatment planning for stereotactic radiosurgery and stereotactic body radiation therapy techniques with 2.5mm and 5mm multileaf collimator (MLC): A pilot study. F1000Res. 2025 Mar 17;13:290.
  28. Paschal HMP, Kabat CN, Papaconstadopoulos P, Kirby NA, Myers PA, Wagner TD, et al. Monte Carlo modeling of the Elekta Versa HD and patient dose calculation with EGSnrc/BEAMnrc. J Appl Clin Med Phys. 2022 Sep;23(9):e13715.
  29. Bedford, J.L. (2009), Treatment planning for volumetric modulated arc therapy. Med. Phys., 36: 5128-5138.
  30. Sikora M, Muzik J, Söhn M, Weinmann M, Alber M. Monte Carlo vs. pencil beam based optimization of stereotactic lung IMRT. Radiat Oncol. 2009 Dec 12;4:64.
  31. Kumawat N, Shrotriya AK, Heigrujam MS, Kumar S, Semwal MK, Bansal AK, et al.. The Composite Planning Technique in Left Sided Breast Cancer Radiotherapy: A Dosimetric Study. Eur J Breast Health. 2020 Apr 1;16(2):137-145.
  32. Srivastava AK, Bharati A, Rastogi M, Mishra SP, Khurana R, Hadi R, et al.. Evaluation of dosimetric implications of Pareto and constrained mode of optimization for Monaco TPS generated VMAT plans in post operated carcinoma of the left breast. Polish Journal of Medical Physics and Engineering. Sciendo, 2021;27}(1): 11-18.
  33. Singh P, Kaur J, Garg C, Petro K, Kumawat N. Dosimetric evaluation of organs at risk by conventional, IMRT and VMAT techniques for post operative radiation therapy in breast cancer. J Cardiovasc Dis Res. 2022 [cited 2025 Sep 15];13(2).
  34. Pyshniak V, Fotina I, Zverava A, Siamkouski S, Zayats E, Kopanitsa G, et al.. Efficiency of biological versus physical optimization for single-arc VMAT for prostate and head and neck cases. J Appl Clin Med Phys. 2014 Jul 8;15(4):4514.
Iranian Journal of Medical Physics
Volume 22, Issue 3 - Serial Number 3
May and June 2025
Pages 194-202

  • Receive Date 26 March 2024
  • Revise Date 16 September 2024
  • Accept Date 22 April 2025