Abstract
BACKGROUND: Studies suggest that integrating robust planning and noncoplanar volumetric modulated arc therapy (VMAT) may be a useful strategy for maximizing the benefits of dose delivery while maintaining resilience to uncertainty; however, the robustness of target coverage and the dose-sparing performance for organs at risk of techniques that combine dynamic trajectory irradiation and robust planning have not been fully investigated. PURPOSE: We aimed to evaluate the combination of biaxially rotational dynamic radiation therapy (BROAD-RT) with robust planning to improve the dosimetric outcomes and robustness of head and neck cancer (HNC) radiation therapy. METHODS: We retrospectively analyzed 10 patients with oropharyngeal and hypopharyngeal cancers who were treated with VMAT. Robust-VMAT, Robust-Non-Coplanar-VMAT (Robust-NC-VMAT), and Robust-BROAD-RT plans were generated using the RayStation treatment planning system, with patient setup uncertainties of 3-5 mm in each of the three axial directions (left-right, anterior-posterior, and superior-inferior) applied to the clinical target volume (CTV) during robust optimization. The prescribed doses were 70 and 56 Gy in 35 fractions for high- and low-risk CTVs, respectively. Dosimetric parameters, including dose coverage for the CTVs and organ at risk (OAR) sparing, were compared between the plans. Robustness was evaluated using eight uncertainty scenarios, each generated by applying ± 1.7 mm translational shifts simultaneously along all three orthogonal axes (left-right, anterior-posterior, and superior-inferior), resulting in a combined vector displacement of approximately 3 mm. RESULTS: The Robust-BROAD-RT plans significantly reduced the mean doses to the contralateral and ipsilateral parotid glands and the oral cavity by 8.17, 6.20, and 3.03 Gy, respectively, compared to the Robust-VMAT plans (p < 0.001, p < 0.001, and p = 0.002, respectively). Similarly, the Robust-BROAD-RT plans achieved significantly lower doses to the parotid glands and the oral cavity compared to the Robust-NC-VMAT plans (p = 0.004, p = 0.014, and p = 0.014, respectively). No significant differences were observed in the target coverage indices (D98, D50), conformity index (CI), or homogeneity index (HI) among the three techniques. The worst-case scenario analysis showed that the degree of deterioration in these target-related parameters did not differ significantly among the Robust-BROAD-RT, Robust-VMAT, and Robust-NC-VMAT plans. CONCLUSIONS: The Robust-BROAD-RT plan achieved a further reduction in doses to the parotid and oral cavities while maintaining robustness comparable to that of conventional Robust VMAT planning.