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To formulate and solve the fluence-map merging procedure of the recently-published VMAT treatment-plan optimization method, called VMERGE, as a bi-criteria optimization problem. Using an exact merging method rather than the previously-used heuristic, we are able to better characterize the trade-off between the delivery efficiency and dose quality. VMERGE begins with a solution of the fluence-map optimization problem with 180 equi-spaced beams that yields the 'ideal' dose distribution. Neighboring fluence maps are then successively merged, meaning that they are added together and delivered as a single map. The merging process improves the delivery efficiency at the expense of deviating from the initial high-quality dose distribution. We replace the original merging heuristic by considering the merging problem as a discrete bi-criteria optimization problem with the objectives of maximizing the treatment efficiency and minimizing the deviation from the ideal dose. We formulate this using a network-flow model that represents the merging problem. Since the problem is discrete and thus non-convex, we employ a customized box algorithm to characterize the Pareto frontier. The Pareto frontier is then used as a benchmark to evaluate the performance of the standard VMERGE algorithm as well as two other similar heuristics. We test the exact and heuristic merging approaches on a pancreas and a prostate cancer case. For both cases, the shape of the Pareto frontier suggests that starting from a high-quality plan, we can obtain efficient VMAT plans through merging neighboring fluence maps without substantially deviating from the initial dose distribution. The trade-off curves obtained by the various heuristics are contrasted and shown to all be equally capable of initial plan simplifications, but to deviate in quality for more drastic efficiency improvements. This work presents a network optimization approach to the merging problem. Contrasting the trade-off curves of the merging heuristics against the Pareto approximation validates that heuristic approaches are capable of achieving high-quality merged plans that lie close to the Pareto frontier.

Exploring trade-offs between VMAT dose quality and delivery efficiency using a network optimization approach