Automated Treatment Planning for Interstitial HDR Brachytherapy for Locally Advanced Cervical Cancer using Deep Reinforcement Learning

High-dose-rate (HDR) brachytherapy plays a critical role in the treatment of locally advanced cervical cancer but remains highly dependent on manual treatment planning expertise. The objective of this study is to develop a fully automated HDR brachytherapy planning framework that integrates reinforcement learning (RL) and dose-based optimization to generate clinically acceptable treatment plans with improved consistency and efficiency. We propose a hierarchical two-stage autoplanning framework. In the first stage, a deep Q-network (DQN)-based RL agent iteratively selects treatment planning parameters (TPPs), which control the trade-offs between target coverage and organ-at-risk (OAR) sparing. The agent's state representation includes both dose-volume histogram (DVH) metrics and current TPP values, while its reward function incorporates clinical dose objectives and safety constraints, including D90, V150, V200 for targets, and D2cc for all relevant OARs (bladder, rectum, sigmoid, small bowel, and large bowel). In the second stage, a customized Adam-based optimizer computes the corresponding dwell time distribution for the selected TPPs using a clinically informed loss function. The framework was evaluated on a cohort of patients with complex applicator geometries. The proposed framework successfully learned clinically meaningful TPP adjustments across diverse patient anatomies. For the unseen test patients, the RL-based automated planning method achieved an average score of 93.89%, outperforming the clinical plans which averaged 91.86%. These findings are notable given that score improvements were achieved while maintaining full target coverage and reducing CTV hot spots in most cases.

Patient-Specific Deep Reinforcement Learning for Automatic Replanning in Head-and-Neck Cancer Proton Therapy

Anatomical changes during intensity-modulated proton therapy (IMPT) for head-and-neck cancer (HNC) can shift Bragg peaks, risking tumor underdosing and organ-at-risk overdosing. As a result, treatment replanning is often required to maintain clinically acceptable treatment quality. However, current manual replanning processes are resource-intensive and time-consuming. We propose a patient-specific deep reinforcement learning (DRL) framework for automated IMPT replanning, with a reward-shaping mechanism based on a $150$-point plan quality score addressing competing clinical objectives. We formulate the planning process as an RL problem where agents learn control policies to adjust optimization priorities, maximizing plan quality. Unlike population-based approaches, our framework trains personalized agents for each patient using their planning CT (Computed Tomography) and augmented anatomies simulating anatomical changes (tumor progression and regression). This patient-specific approach leverages anatomical similarities throughout treatment, enabling effective plan adaptation. We implemented two DRL algorithms, Deep Q-Network and Proximal Policy Optimization, using dose-volume histograms (DVHs) as state representations and a $22$-dimensional action space of priority adjustments. Evaluation on five HNC patients using actual replanning CT data showed both DRL agents improved initial plan scores from $120.63 \pm 21.40$ to $139.78 \pm 6.84$ (DQN) and $142.74 \pm 5.16$ (PPO), surpassing manual replans generated by a human planner ($137.20 \pm 5.58$). Clinical validation confirms that improvements translate to better tumor coverage and OAR sparing across diverse anatomical changes. This work demonstrates DRL's potential in addressing geometric and dosimetric complexities of adaptive proton therapy, offering efficient offline adaptation solutions and advancing online adaptive proton therapy.