In House Automated Planning Scripts Implemented

Clinically using Phillips Pinnacle Planning System

Rose. Ca , Holloway. Sa,b , Evans. Ba , & Hoole. Aa
a. Department of Medical Physics, Cambridge University Hospitals NHS Foundation
Trust
b. Department of Medical Physics & Biomedical Engineering, University College
London
E-mail: s.holloway@ucl.ac.uk

Autumn 2017

Abstract. The Pinnacle planning system includes a scripting language which

provides users with the tools required to program simple automated processes.
Automated Real Time Scripts (ARTS) are in-house Pinnacle scripts designed as a
hybrid between the class and the progressive solutions for plan automation. ARTS
have been created to streamline aspects of treatment planning in our radiotherapy
department.
The ARTS algorithm employs a mixture of Pinnacle and Perl scripts to enable
the automated generation of optimised pre-plans. The algorithm follows a well-
defined process which begins by loading a class solution. The ARTS algorithm
effectively emulates a human planner by converging on an optimal set of IMRT planning
objectives, which are then used to calculate the final dose distribution. Planning
objectives are modified by passing out DVH, weightings and objective values to external
Perl scripts which analyse the data using a simple decision tree and modifies the
objectives appropriately.
The analysis of dose statistics from planner-produced plans can be used to refine the
ARTS algorithm, therefore enabling the creation of pre-plans that are representative
of the quality currently being achieved in this department. The ARTS algorithm is
currently capable of achieving clinically acceptable plans, relative to the objectives laid
out in our department’s prostate protocol. ARTS for VMAT prostate provides a time
saving of 1 hour and 25 minutes per plan.
The implementation of auto-planning provides a significant time saving and a
reduction of workload within the department and the use of ARTs is being further
developed to plan other treatment sites.

1. Introduction

With predicted increase in number of patients requiring radiotherapy in England

between now and 2020 (Round et al, 2013) and increased pressures on resources,
radiotherapy departments are looking to methods of standardisation and automation
to improve work-flow efficiency. The creation of treatment planning scripts within the
Automated Real Time Scripts in Clinical Treatment Planning 2

radiotherapy department is one such solution that has allowed for repetitive and routine
tasks to be automated, therefore speeding up the planning process and reducing user
errors. Using forward planning techniques many of the tasks can be automated, Mitchell
et al, 2017 investigated automation techniques into breast radiotherapy planning
practice through commercially available auto-segmentation software and non- complex,
non-commercial scripting solutions within a commercial treatment planning system.
Scripts have also been created to be used by the planner to check for common errors
in an effort to reduce the incidence of re-plans. And, finally, they have been used to
optimise the plan itself allowing for auto-planning. Wang et al, 2016 concluded in their
paper that clinical inverse treatment planning process can be automated effectively with
the guidance of an assemble of prior treatment plans and that this approach has the
potential to significantly improve the radiation therapy work-flow.

Several commercial planning systems utilise scripting including RaySearch, Eclipse

and Pinnacle. At our centre we used the Pinnacle planning system. When developing
scripts to be used in Pinnacle, the user produces scripts that manipulate a Black Box
planning system through the use of a combination of external programming languages
and Pinnacles own, unsupported, scripting language - also named Pinnacle. Pinnacle
provides users with the tools required to program simple automated processes; such
as growing planning structures, setting up IMRT parameters and generating planning
protocols, or class solutions. Pinnacle’s scripting language also provides a limited set
of functions which enable the use of external scripts written in other programming
languages, such as Perl and Python.

In this paper we describe the scripting process of an in-house Automated Real

Time Scripts (ARTS) process developed at Addenbrooke’s and present the results from
using ARTS for planning VMAT prostate plans to be used clinically in our department.
The aim of ARTs was to utilise the functionality of the Pinnacle scripting language
to reduce time required by planners to create standard VMAT prostate plans and
reduce incidences of planning errors that would be picked up at plan checking, but
which require more planning time. To automatically manoeuvre the clinical treatment
planning process at Addenbrooke’s we have used clearly defined protocols established
by our clinicians for treating standard prostate patients to drive the optimisation to
achieve a clinically suitable plan. The goal of which was go achieve a plan automatically,
without human interaction, that would meet all objectives and constraints as stated in
the protocol, yet may still require further individualisation by an experienced planner.

2. Methods

2.1. ARTS Algorithm

The ARTS algorithm employs a mixture of Pinnacle and Perl scripts to enable the
automated generation of optimised VMAT prostate plans. The algorithm follows a
Automated Real Time Scripts in Clinical Treatment Planning 3

well-defined process which begins by loading a class solution which automates PTV
growth, plan structure generation, isocenter placement and the definition of optimisation
parameters. After loading the class solution the algorithm fully automates the
optimisation of the plan by dynamically modifying planning objectives within Pinnacle.
Planning objectives are modified by passing out objective dose, volume, weighting and
composite objective values to external Perl scripts, which then analyse the data using
a simple decision tree that effectively mimics the human planner decision process. The
algorithm leverages the availability of Pinnacles composite objective values. Each user-
specified planning objective has its own objective value, which is a measure of how
close the dose distribution is to meeting that objective. The algorithm compares the
magnitude of each objective value, relative to the total objective value to determine if an
objective requires modification. Objectives with relatively small values will have a more
stringent set of dose, volume and weighting parameters applied; and objectives with
relatively large objective values will have a less stringent set of parameters applied. The
results of the algorithms analysis are used to update the planning objective list within
Pinnacle. Each time the planning objectives are modified the plan is reset and re-
optimised with the new parameters. After a few optimisations the algorithm converges
on an optimal set of planning parameters, resulting in a plan which automatically has
favourable organ at risk dose statistics.

2.2. Quality Assurance

Due the nature of using scripts, there is an inherent risk of systematic errors being
introduced into the planning process. Even well designed scripts can produce erroneous
results when applied in a non-standard setting. Because a scripts interaction with
the planning system is necessarily superficial, unsupported by the vendor and script
users have little insight with regard to the internal processes performed by Pinnacle,
it is necessary to have in place a well-designed script development framework and
accompanying quality system. At Addenbrooke’s we have implemented a quality system
which covers the entire process of scripting from script proposals through to clinical
implementation. The scripting specific quality system implemented at Addenbrooke’s
complies with ISO 9001 standard and its accompanying software specific guidelines,
ISO 9000-3. The scripting specific quality system is also in line with the pre-existing
Addenbrooke’s quality system for the development of in-house software. The work-flow
of this process is shown in Figure 1.

3. Results

The development of the ARTS algorithm led to the review of our departments prostate
protocol and the tightening of organ at risk planning objectives. The dose objectives
given in Table 1 represent our current clinical protocol and contains average dose-
volume statistics for 30 clinically acceptable ARTS VMAT prostate plans. The statistics
Automated Real Time Scripts in Clinical Treatment Planning 4

figures/QAflow.PNG

Figure 1. Schematic of script quality assurance pathway implemented at

Addenbrooke’s Radiotherapy Department

Table 1. Average organ at risk dose-volume statistics for 30 clinically acceptable

ARTS VMAT prostate plans.
Organ Dose Objective Volume Objective(%) Average(Gy)
PTV PG V64.2Gy Zero 62.04
PTV PG V57Gy >99 99.74
PTV SV V49.4Gy >99 99.93
Rectum V24.6Gy 80 61.62
Rectum V32.4Gy 70 46.21
Rectum V40.8Gy 60 31.83
Rectum V48.6Gy 50 20.24
Rectum V52.8Gy 30 11.93
Rectum V57Gy 15 6.17
Rectum V60Gy 3 0.54
Bladder V40.8Gy 50 17.18
Bladder V48.6Gy 25 11.88
Bladder V60Gy 5 1.96

provided in Table 1 demonstrate that, on average, the ARTS algorithm is able to

generate plans with favourable organ at risk statistic, which pass planning objectives by
a comfortable margin.

Figure 2 is an example of both an ARTS generated and human generated prostate

dose distribution. Upon inspection the ARTS generated plan has a much more
symmetric dose distribution, with improved high dose conformity. In this particular
example the ARTS generated plan was much less modulated than the Human planned
equivalent. The difference, in terms of modulation, is highlighted by the conformity and
smoothness of the 20Gy isodose line in the ARTS distribution.

As part of the development process 10 prostate patients have been dual planned
by Human planners and the ARTS algorithm. Table 2 includes average dose-volume
statistics for all 10 patients. In general the ARTS algorithm shows slightly better organ
at risk dose statistics whilst sacrificing a small amount of PTV coverage. In general the
difference between the Human and ARTS dose statistics are small, meaning that the
ARTS generated plans are at least equivalent to their Human planned counterparts.
Automated Real Time Scripts in Clinical Treatment Planning 5

figures/splash.PNG

Figure 2. ARTS generated plan (left) and Manual plan (right)

4. Discussion

The ARTS algorithm has been commissioned for use in our department and has been
Incorporated into the VMAT prostate planning work-flow. All prostate plans are
initially planned using the ARTS algorithm and later assessed by an experienced VMAT
planner. Any sub-optimal plans are adjusted and re-optimised before being released for
checking.

The implementation of auto-planning has increased plan quality and plan

consistency within our department, with around 90% of ARTS plans being deemed
clinically acceptable without the need for further intervention. However, non-standard,
Automated Real Time Scripts in Clinical Treatment Planning 6

Table 2. Average organ at risk dose-volume statistics for 10 prostates dual planned
by both a Human planner and the ARTS algorithm.
Organ Dose Objective Volume Objective(%) ARTS Average(Gy) Human Average(Gy)
PTV PG V64.2Gy Zero 62.10 61.46
PTV PG V57Gy >99 99.75 99.81
PTV SV V49.4Gy >99 99.90 99.83
Rectum V24.6Gy 80 63.13 61.63
Rectum V32.4Gy 70 46.10 46.7
Rectum V40.8Gy 60 30.19 31.46
Rectum V48.6Gy 50 18.44 19.46
Rectum V52.8Gy 30 10.50 11.16
Rectum V57Gy 15 5.30 5.71
Rectum V60Gy 3 0.70 0.90
Bladder V40.8Gy 50 20.93 22.05
Bladder V48.6Gy 25 15.04 16.04
Bladder V60Gy 5 2.74 1.92

or more complicated plans, can cause an issue for the algorithm because of its limited
ability to compromise planning objectives. In such cases the algorithm generates sub-
optimal plans which require further modification by experienced planning technicians.

The implementation of auto-planning has also improved planning work-flow within

the department by providing significant time savings. On average, an experienced
planning technician takes up to 2 hours to plan a VMAT prostate plan whereas the
ARTS algorithm produces a plan in 35 minutes, providing a time saving of 1 hour and 25
minutes per plan. Between October and December 2015, 167 hours of planning time was
scheduled for planning VMAT prostates at Addenbrooke’s hospital. The implementation
of ARTs for VMAT prostate has allowed for the release approximately eight weeks in
scheduled planning time for VMAT prostate per year.

Aside from providing a significant time saving, the use of ARTS also frees up a
planner to complete other tasks whilst the algorithm is running, therefore increasing
output and efficiency. ARTs is currently being developed for other VMAT treatment
sites including rectum, bladder and head and neck. Protocols for DMPO plans are also
being extended along with ARTS into a new planning work-flow utilising scripting. This
will allow the plan to be created and finalised in a couple of mouse clicks.

One of the challenges experienced was the lack of a naming convention used in the
department which made scripting difficult. As the department moved towards more
script based planning, naming conventions began to be used as this allowed planners to
use the scripts.
Automated Real Time Scripts in Clinical Treatment Planning 7

5. Conclusion

The implementation of auto-planning provides a significant time saving and a reduction

of workload within the department; therefore enabling experienced planning technicians
to apply their skills on more complex plans. The algorithm applies the same set of
planning rules to each VMAT prostate plan, such that each plan is produced in a
regularised manner and is independent of a planning technician’s idiosyncrasies.

Theoretically, each patient planned by the algorithm will receive the same quality
of plan, wherein each planning objective is achieved and each individual organ at risk
receives its minimal possible dose. Currently, the algorithm can achieve planning goals
for 90 percent of standard prostate plans; and further developments, based on user
feedback, will increase the algorithm’s overall efficiency.

The relative success of the original algorithm has led the development of a
generalised version of ARTS, which is capable of planning multiple sites with multiple
prescriptions, independent of the planning objectives specified by the planner.

6. Acknowledgements

We would like to acknowledge the radiotherapy treatment planning team at

Addenbrooke’s Hospital.
Automated Real Time Scripts in Clinical Treatment Planning 8

References

Round, C. E. et al. (2013) Radiotherapy Demand and Activity in England 2006-2020, Clinical Oncology,
25(9), pp. 522-530. doi: 10.1016/j.clon.2013.05.005.
Mitchell, R. A. et al. (2017) Improving the efficiency of breast radiotherapy treatment planning using a
semi-automated approach, (March 2016), pp. 18-24. doi: 10.1002/acm2.12006.
Wang, H. et al. (2017) Development of an autonomous treatment planning strategy for radiation
therapy with effective use of population-based prior data, Medical Physics, 44(2), pp. 389-396. doi:
10.1002/mp.12058.