Clinical DVH metrics as a loss function for 3D dose prediction in head and neck radiotherapy.

PURPOSE: Deep learning-based three-dimensional (3D) dose prediction is widely used in automated radiotherapy workflows. However, most existing models are trained with voxel-wise regression losses, which are poorly aligned with clinical plan evaluation criteria based on dose-volume histogram (DVH) metrics. This study aims to develop a clinically guided loss formulation that directly optimizes clinically used DVH metrics while remaining computationally efficient for head and neck (H&N) dose prediction. METHODS: We propose a clinical DVH metric loss (CDM loss) that incorporates differentiable D-metrics and surrogate V-metrics, together with a lossless bit-mask region-of-interest (ROI) encoding to improve training efficiency. The method was evaluated on 174 H&N patients using a temporal split (137 training, 37 testing). RESULTS: Compared with MAE- and DVH curve-based losses, CDM loss substantially improved target coverage and satisfied all clinical constraints. Using a standard 3D U-Net, the PTV Score was reduced from 1.544 (MAE) to 0.491 (MAE + CDM), while OAR sparing remained comparable. Bit-mask encoding reduced training time by 82.2% and lowered GPU memory usage. CONCLUSION: Directly optimizing clinically used DVH metrics enables 3D dose predictions that are better aligned with clinical treatment planning criteria than conventional voxel-wise or DVH curve-based supervision. The proposed CDM loss, combined with efficient ROI bit-mask encoding, provides a practical and scalable framework for H&N dose prediction.