{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T05:16:43Z","timestamp":1784092603927,"version":"3.55.0"},"reference-count":32,"publisher":"Wiley","issue":"5","license":[{"start":{"date-parts":[[2018,8,11]],"date-time":"2018-08-11T00:00:00Z","timestamp":1533945600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["aapm.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J Applied Clin Med Phys"],"published-print":{"date-parts":[[2018,9]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:p>Target dose uniformity has been historically an aim of volumetric modulated arc therapy (<jats:styled-content style=\"fixed-case\">VMAT<\/jats:styled-content>) planning. However, for some sites, this may not be strictly necessary and removing this constraint could theoretically improve organ\u2010at\u2010risk (<jats:styled-content style=\"fixed-case\">OAR<\/jats:styled-content>) sparing and tumor control probability (<jats:styled-content style=\"fixed-case\">TCP<\/jats:styled-content>). This study systematically investigates the consequences of <jats:styled-content style=\"fixed-case\">PTV<\/jats:styled-content> dose uniformity that results from the application or removal of an upper dose constraint (<jats:styled-content style=\"fixed-case\">UDC<\/jats:styled-content>) in the inverse planning process for prostate <jats:styled-content style=\"fixed-case\">VMAT<\/jats:styled-content> treatments. <jats:styled-content style=\"fixed-case\">OAR<\/jats:styled-content> sparing, target coverage, hotspots, and plan complexity were compared between prostate <jats:styled-content style=\"fixed-case\">VMAT<\/jats:styled-content> plans with and without the <jats:styled-content style=\"fixed-case\">PTV UDC<\/jats:styled-content> optimized using the progressive resolution optimizer (<jats:styled-content style=\"fixed-case\">PRO<\/jats:styled-content>, Varian Medical Systems, Palo Alto, <jats:styled-content style=\"fixed-case\">CA<\/jats:styled-content>). Removing the <jats:styled-content style=\"fixed-case\">PTV UDC<\/jats:styled-content>, the median D1cc reached 144.6% for the <jats:styled-content style=\"fixed-case\">CTV<\/jats:styled-content> and the <jats:styled-content style=\"fixed-case\">PTV<\/jats:styled-content>, and an average increase of 3.2% <jats:styled-content style=\"fixed-case\">TCP<\/jats:styled-content> was demonstrated, while <jats:styled-content style=\"fixed-case\">CTV<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">PTV<\/jats:styled-content> coverage evaluated by D99% was decreased by less than 0.6% with statistical significance. Moreover, systematic improvement in the rectum dose volume histograms was shown (a 5\u201310% decrease in the volume receiving 50% to 75% prescribed dose), resulting in an average decrease of 1.3% (<jats:italic>P<\/jats:italic>\u00a0&lt;\u00a00.01) in the rectum normal tissue complication probability. Additional consequences included potentially increased dose to the urethra as evaluated by <jats:styled-content style=\"fixed-case\">PTV<\/jats:styled-content> D0.035cc (median: 153.4%), delivering 283 extra monitor units (<jats:styled-content style=\"fixed-case\">MU<\/jats:styled-content>s), and slightly higher degrees of modulation. In general, the results were consistent when a different optimizer (Photon Optimizer, Varian Medical Systems) was used. In conclusion, removing the <jats:styled-content style=\"fixed-case\">PTV UDC<\/jats:styled-content> is acceptable for localized prostate cases given the systematic improvement of rectal dose and <jats:styled-content style=\"fixed-case\">TCP<\/jats:styled-content>. It can be particularly useful for cases that do not meet the rectum dose constraints with the <jats:styled-content style=\"fixed-case\">PTV UDC<\/jats:styled-content> on. This comes with the foreseeable consequences of increased dose heterogeneity in the <jats:styled-content style=\"fixed-case\">PTV<\/jats:styled-content> and an increase in <jats:styled-content style=\"fixed-case\">MU<\/jats:styled-content>s and plan complexity. It also has a higher requirement for reproducing the position and size of the target and <jats:styled-content style=\"fixed-case\">OAR<\/jats:styled-content>s during treatment. Finally, with the <jats:styled-content style=\"fixed-case\">PTV UDC<\/jats:styled-content> completely removed, in some cases the maximum doses within the <jats:styled-content style=\"fixed-case\">PTV<\/jats:styled-content> did approach levels that may be of concern for urethral toxicity and therefore in clinical implementation it may still be necessary to include a <jats:styled-content style=\"fixed-case\">PTV UDC<\/jats:styled-content>, but one based on limiting toxicity rather than enforcing dose homogeneity.<\/jats:p>","DOI":"10.1002\/acm2.12424","type":"journal-article","created":{"date-parts":[[2018,8,12]],"date-time":"2018-08-12T04:09:33Z","timestamp":1534046973000},"page":"580-590","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":12,"title":["A quantitative assessment of the consequences of allowing dose heterogeneity in prostate radiation therapy planning"],"prefix":"10.1002","volume":"19","author":[{"given":"Lingyue","family":"Sun","sequence":"first","affiliation":[{"name":"Department of Physics and Astronomy University of Calgary Calgary AB Canada"},{"name":"Department of Medical Physics Tom Baker Cancer Centre Calgary AB Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wendy","family":"Smith","sequence":"additional","affiliation":[{"name":"Department of Physics and Astronomy University of Calgary Calgary AB Canada"},{"name":"Department of Medical Physics Tom Baker Cancer Centre Calgary AB Canada"},{"name":"Department of Oncology University of Calgary Calgary AB Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abhijit","family":"Ghose","sequence":"additional","affiliation":[{"name":"Department of Oncology University of Calgary Calgary AB Canada"},{"name":"Department of Radiation Oncology Jack Ady Cancer Centre Lethbridge AB Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charles","family":"Kirkby","sequence":"additional","affiliation":[{"name":"Department of Physics and Astronomy University of Calgary Calgary AB Canada"},{"name":"Department of Oncology University of Calgary Calgary AB Canada"},{"name":"Department of Medical Physics Jack Ady Cancer Centre Lethbridge AB Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2018,8,11]]},"reference":[{"key":"e_1_2_8_2_1","doi-asserted-by":"publisher","DOI":"10.1088\/0031-9155\/38\/6\/001"},{"key":"e_1_2_8_3_1","doi-asserted-by":"crossref","unstructured":"International Commission on Radiation Units and Measurements.Prescribing recording and reporting photon beam therapy (ICRU report 50).ICRU Rep.1993;21(November):357\u2013360.","DOI":"10.1118\/1.597396"},{"key":"e_1_2_8_4_1","unstructured":"International Commission on Radiation Units and Measurements.ICRU Report 62. 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