Contouring practices and artefact management within a synthetic CT-based radiotherapy workflow for the central nervous system.

BACKGROUND: The incorporation of magnetic resonance (MR) imaging in radiotherapy (RT) workflows improves contouring precision, yet it introduces geometrical uncertainties when registered with computed tomography (CT) scans. Synthetic CT (sCT) images could minimize these uncertainties and streamline the RT workflow. This study aims to compare the contouring capabilities of sCT images with conventional CT-based/MR-assisted RT workflows, with an emphasis on managing artefacts caused by surgical fixation devices (SFDs). METHODS: The study comprised a commissioning cohort of 100 patients with cranial tumors treated using a conventional CT-based/MR-assisted RT workflow and a validation cohort of 30 patients with grade IV glioblastomas treated using an MR-only workflow. A CE-marked artificial-intelligence-based sCT product was utilized. The delineation accuracy comparison was performed using dice similarity coefficient (DSC) and average Hausdorff distance (AHD). Artefacts within the commissioning cohort were visually inspected, classified and an estimation of thickness was derived using Hausdorff distance (HD). For the validation cohort, boolean operators were used to extract artefact volumes adjacent to the target and contrasted to the planning treatment volume. RESULTS: The combination of high DSC (0.94) and low AHD (0.04 mm) indicates equal target delineation capacity between sCT images and conventional CT scans. However, the results for organs at risk delineation were less consistent, likely because of voxel size differences between sCT images and CT scans and absence of standardized delineation routines. Artefacts observed in sCT images appeared as enhancements of cranial bone. When close to the target, they could affect its definition. Therefore, in the validation cohort the clinical target volume (CTV) was expanded towards the bone by 3.5 mm, as estimated by HD analysis. Subsequent analysis on cone-beam CT scans showed that the CTV adjustment was enough to provide acceptable target coverage. CONCLUSION: The tested sCT product performed on par with conventional CT in terms of contouring capability. Additionally, this study provides both the first comprehensive classification of metal artefacts on a sCT product and a novel method to assess the clinical impact of artefacts caused by SFDs on target delineation. This methodology encourages similar analysis for other sCT products.

Clinical implementation of a commercial synthetic computed tomography solution for radiotherapy treatment of glioblastoma.

Background and Purpose: Magnetic resonance (MR)-only radiotherapy (RT) workflow eliminates uncertainties due to computed tomography (CT)-MR image registration, by using synthetic CT (sCT) images generated from MR. This study describes the clinical implementation process, from retrospective commissioning to prospective validation stage of a commercial artificial intelligence (AI)-based sCT product. Evaluation of the dosimetric performance of the sCT is presented, with emphasis on the impact of voxel size differences between image modalities. Materials and methods: sCT performance was assessed in glioblastoma RT planning. Dose differences for 30 patients in both commissioning and validation cohorts were calculated at various dose-volume-histogram (DVH) points for target and organs-at-risk (OAR). A gamma analysis was conducted on regridded image plans. Quality assurance (QA) guidelines were established based on commissioning phase results. Results: Mean dose difference to target structures was found to be within ± 0.7 % regardless of image resolution and cohort. OARs' mean dose differences were within ± 1.3 % for plans calculated on regridded images for both cohorts, while differences were higher for plans with original voxel size, reaching up to -4.2 % for chiasma D2% in the commissioning cohort. Gamma passing rates for the brain structure using the criteria 1 %/1mm, 2 %/2mm and 3 %/3mm were 93.6 %/99.8 %/100 % and 96.6 %/99.9 %/100 % for commissioning and validation cohorts, respectively. Conclusions: Dosimetric outcomes in both commissioning and validation stages confirmed sCT's equivalence to CT. The large patient cohort in this study aided in establishing a robust QA program for the MR-only workflow, now applied in glioblastoma RT at our center.