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Clough A, Chuter R, Hales RB, Parker J, McMahon J, Whiteside L, McHugh L, Davies L, Sanders J, Benson R, Nelder C, McDaid L, Choudhury A, Eccles CL. Impact of a contouring atlas on radiographer inter-observer variation in male pelvis radiotherapy. J Med Imaging Radiat Sci 2024; 55:281-288. [PMID: 38609834 DOI: 10.1016/j.jmir.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/26/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024]
Abstract
PURPOSE/OBJECTIVE To determine the impact of a MR-based contouring atlas for male pelvis radiotherapy delineation on inter-observer variation to support radiographer led real-time magnetic resonance image guided adaptive radiotherapy (MRgART). MATERIAL/METHODS Eight RTTs contoured 25 MR images in the Monaco treatment planning system (Monaco 5.40.01), from 5 patients. The prostate, seminal vesicles, bladder, and rectum were delineated before and after the introduction of an atlas developed through multi-disciplinary consensus. Inter-observer contour variations (volume), time to contour and observer contouring confidence were determined at both time-points using a 5-point Likert scale. Descriptive statistics were used to analyse both continuous and categorical variables. Dice similarity coefficient (DSC), Dice-Jaccard coefficient (DJC) and Hausdorff distance were used to calculate similarity between observers. RESULTS Although variation in volume definition decreased for all structures among all observers post intervention, the change was not statistically significant. DSC and DJC measurements remained consistent following the introduction of the atlas for all observers. The highest similarity was found in the bladder and prostate whilst the lowest was the seminal vesicles. The mean contouring time for all observers was reduced by 50% following the introduction of the atlas (53 to 27 minutes, p=0.01). For all structures across all observers, the mean contouring confidence increased significantly from 2.3 to 3.5 out of 5 (p=0.02). CONCLUSION Although no significant improvements were observed in contour variation amongst observers, the introduction of the consensus-based contouring atlas improved contouring confidence and speed; key factors for a real-time RTT-led MRgART.
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Affiliation(s)
- Abigael Clough
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Robert Chuter
- The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Rosie B Hales
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Jacqui Parker
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - John McMahon
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Lee Whiteside
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Louise McHugh
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Lucy Davies
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Rebecca Benson
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Claire Nelder
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Lisa McDaid
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Ananya Choudhury
- The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Cynthia L Eccles
- The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.
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Onal C, Bozca R, Dolek Y, Elmali A, Guler OC. A Comparative Analysis of Implant-sparing Plan Versus Conventional Plans Utilizing Helical Tomotherapy in Breast Cancer Patients Undergoing Breast Reconstruction. In Vivo 2024; 38:1412-1420. [PMID: 38688603 PMCID: PMC11059874 DOI: 10.21873/invivo.13583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND/AIM To compare implant sparing irradiation with conventional radiotherapy (RT) using helical (H) and TomoDirect (TD) techniques in breast cancer patients undergoing immediate breast reconstruction (IBR). PATIENTS AND METHODS The dosimetric parameters of 40 patients with retropectoral implants receiving 50.4 Gy delivered in 28 fractions were analyzed. Three plans were created: H plan using conventional planning target volume (PTV) that included the chest wall, skin, and implant; TD plan using conventional PTV; and Hs plan using implant-sparing PTV. The H, TD, and Hs plans were compared for PTV doses, organ-at-risk (OAR) doses, and treatment times. RESULTS Dose distribution in the Hs plan was less homogeneous and uniform than that in the H and TD plans. The TD plan had lower lung, heart, contralateral breast, spinal cord, liver, and esophagus doses than the Hs plan. Compared to the Hs plan, the H plan had lower lung volume receiving 5Gy (V5) (39.1±3.9 vs. 41.2±3.9 Gy; p<0.001), higher V20 (12.3±1.3 vs. 11.5±2.6 Gy; p=0.02), and higher V30 (7.5±1.6 vs. 4.4±1.7 Gy; p<0.001). H plan outperformed Hs plan in heart dosimetric parameters except V20. The Hs plan had significantly lower mean implant doses (43.4±2.1 Gy) than the H plan (51.4±0.5 Gy; p<0.001) and the TD plan (51.9±0.6 Gy; p<0.001). Implementing an implant sparing technique for silicone dose reduction decreases lung doses. CONCLUSION Conventional H and TD plans outperform the implant sparing helical plan dosimetrically. Because capsular contracture during RT is unpredictable, long-term clinical outcomes are required to determine whether silicon should be spared.
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Affiliation(s)
- Cem Onal
- Department of Radiation Oncology, Baskent University Faculty of Medicine Adana Dr Turgut Noyan Research and Treatment Center, Adana, Turkey;
- Department of Radiation Oncology, Baskent University Faculty of Medicine, Ankara, Turkey
| | - Recep Bozca
- Department of Radiation Oncology, Baskent University Faculty of Medicine, Ankara, Turkey
| | - Yemliha Dolek
- Department of Radiation Oncology, Baskent University Faculty of Medicine Adana Dr Turgut Noyan Research and Treatment Center, Adana, Turkey
| | - Aysenur Elmali
- Department of Radiation Oncology, Baskent University Faculty of Medicine, Ankara, Turkey
| | - Ozan Cem Guler
- Department of Radiation Oncology, Baskent University Faculty of Medicine Adana Dr Turgut Noyan Research and Treatment Center, Adana, Turkey
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Ratnayake G, Huo M, Mehta A, Ramachandran P, Pinkham MB, Law P, Watkins T, Olson S, Hall B, Brown S, Lusk R, Jones C, O’Mahoney E, McGill G, Foote MC. Utility of 68Ga-DOTATATE PET-MRI for Gamma Knife® stereotactic radiosurgery treatment planning for meningioma. Br J Radiol 2024; 97:180-185. [PMID: 38263827 PMCID: PMC11027229 DOI: 10.1093/bjr/tqad026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 10/06/2023] [Accepted: 10/13/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVES To investigate the impact of adding 68Ga-DOTATATE PET/MRI to standard MRI for target volume delineation in Gamma Knife® stereotactic radiosurgery (GKSRS) for meningioma. METHODS Seventeen patients with 18 lesions undergoing GKSRS for WHO grade 1 meningioma were enrolled in a prospective study. All patients underwent pre-treatment 68Ga-DOTATATE PET/MRI examination in addition to standard procedures. Five clinicians independently contoured the gross tumour volume (GTV) based on standard MRI (GTVMRI) and PET/MRI (GTVPET/MRI) on separate occasions. Interobserver agreement was evaluated using Cohen's Kappa statistic (CKS), Dice similarity coefficient (DC), and Hausdorff distance (HD). Statistical analysis was performed with paired t-test and Wilcoxon signed rank test. RESULTS The addition of PET/MRI significantly increased GTV contour volume (mean GTVPET/MRI 3.59 cm3 versus mean GTVMRI 3.18 cm3, P = .008). Using the treating clinician's pre-treatment GTVMRI as the reference, median CKS (87.2 vs 77.5, P = .006) and DC (87.2 vs 77.4, P = .006) were significantly lower, and median HD (25.2 vs 31.0, P = .001) was significantly higher with the addition of PET/MRI. No significant difference was observed in interobserver contouring reproducibility between GTVMRI and GTVPET/MRI. CONCLUSION The addition of 68Ga-DOTATATE PET/MRI for target volume delineation in GKSRS for meningioma is associated with an increase in GTV volume and greater interobserver variation. PET/MRI did not affect interobserver contouring reproducibility. ADVANCES IN KNOWLEDGE This study provides novel insights into the impact of 68Ga-DOTATATE PET/MRI on GTV delineation and interobserver agreement in meningioma GKSRS, highlighting its potential for improving GKSRS treatment accuracy.
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Affiliation(s)
- Gishan Ratnayake
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
| | - Michael Huo
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
| | - Akash Mehta
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
| | - Prabhakar Ramachandran
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
| | - Mark B Pinkham
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
| | - Phillip Law
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
- Department of Medical Imaging, Princess Alexandra Hospital, Brisbane 4102, Australia
| | - Trevor Watkins
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
- Department of Medical Imaging, Princess Alexandra Hospital, Brisbane 4102, Australia
| | - Sarah Olson
- Department of Medical Imaging, Princess Alexandra Hospital, Brisbane 4102, Australia
- Department of Neurosurgery, Princess Alexandra Hospital, Brisbane 4102, Australia
| | - Bruce Hall
- Department of Medical Imaging, Princess Alexandra Hospital, Brisbane 4102, Australia
- Department of Neurosurgery, Princess Alexandra Hospital, Brisbane 4102, Australia
| | - Simon Brown
- Department of Medical Imaging, Princess Alexandra Hospital, Brisbane 4102, Australia
- Department of Neurosurgery, Princess Alexandra Hospital, Brisbane 4102, Australia
| | - Ryan Lusk
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane 4102, Australia
| | - Catherine Jones
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane 4102, Australia
| | - Eoin O’Mahoney
- Department of Medical Imaging, Princess Alexandra Hospital, Brisbane 4102, Australia
| | - George McGill
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane 4102, Australia
| | - Matthew C Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
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Kraja F, Kauweloa K, Ganju RG, Hoover AC. Impact of bowel space contouring variability on radiation dose and volume assessments in treatment planning for gynaecologic cancers. J Med Radiat Sci 2023; 70:417-423. [PMID: 37394743 PMCID: PMC10715335 DOI: 10.1002/jmrs.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/20/2023] [Indexed: 07/04/2023] Open
Abstract
INTRODUCTION Correlations between radiation dose/volume measures and small bowel (SB) toxicity are inconsistent in the medical literature. We assessed the impact of inter-provider variation in bowel bag contouring technique on estimates of radiation dose received by the SB during pelvic radiotherapy. METHODS Ten radiation oncologists contoured rectum, bladder and bowel bags on treatment planning computed tomography (CT) scans of two patients receiving adjuvant radiation for endometrial cancer. A radiation plan was generated for each patient and used to determine the radiation dose/volume for each organ. Kappa statistics were applied to assess the inter-provider contouring agreement, and Levene test evaluated the homogeneity of variance for radiation dose/volume metrics, including the V45Gy (cm3 ). RESULTS The bowel bag showed greater variation in radiation dose/volume estimates compared to the bladder and rectum. The V45Gy ranged from 163 to 384 cm3 for data set A and 109 to 409 cm3 for dataset B. Kappa values were 0.82/0.83, 0.92/0.92 and 0.94/0.86 for the bowel bag, rectum, and bladder on data sets A/B, demonstrating lower inter-provider agreement for bowel bag compared with bladder and rectum. CONCLUSION Inter-provider contouring variability is more significant for the bowel bag than the rectum and bladder, with an associated greater variability in dose and volume estimates during radiation planning.
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Affiliation(s)
- Fatjona Kraja
- Department of OncologyUniversity Hospital Centre Mother TeresaTiranaAlbania
| | - Kevin Kauweloa
- Department of Radiation OncologyQueen's Medical CentreHonoluluHawaiiUSA
| | | | - Andrew C. Hoover
- Department of Radiation OncologyUniversity of Kansas Cancer Centre, Kansas University Medical CentreKansas CityKansasUSA
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Kraja F, Kauweloa K, Ganju RG, Hoover AC. Impact of bowel space contouring variability on radiation dose and volume assessments in treatment planning for gynaecologic cancers. J Med Radiat Sci 2023. [DOI: doi.org/10.1002/jmrs.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/20/2023] [Indexed: 09/03/2023] Open
Abstract
AbstractIntroductionCorrelations between radiation dose/volume measures and small bowel (SB) toxicity are inconsistent in the medical literature. We assessed the impact of inter‐provider variation in bowel bag contouring technique on estimates of radiation dose received by the SB during pelvic radiotherapy.MethodsTen radiation oncologists contoured rectum, bladder and bowel bags on treatment planning computed tomography (CT) scans of two patients receiving adjuvant radiation for endometrial cancer. A radiation plan was generated for each patient and used to determine the radiation dose/volume for each organ. Kappa statistics were applied to assess the inter‐provider contouring agreement, and Levene test evaluated the homogeneity of variance for radiation dose/volume metrics, including the V45Gy (cm3).ResultsThe bowel bag showed greater variation in radiation dose/volume estimates compared to the bladder and rectum. The V45Gy ranged from 163 to 384 cm3 for data set A and 109 to 409 cm3 for dataset B. Kappa values were 0.82/0.83, 0.92/0.92 and 0.94/0.86 for the bowel bag, rectum, and bladder on data sets A/B, demonstrating lower inter‐provider agreement for bowel bag compared with bladder and rectum.ConclusionInter‐provider contouring variability is more significant for the bowel bag than the rectum and bladder, with an associated greater variability in dose and volume estimates during radiation planning.
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Affiliation(s)
- Fatjona Kraja
- Department of Oncology University Hospital Centre Mother Teresa Tirana Albania
| | - Kevin Kauweloa
- Department of Radiation Oncology Queen's Medical Centre Honolulu Hawaii USA
| | | | - Andrew C. Hoover
- Department of Radiation Oncology University of Kansas Cancer Centre, Kansas University Medical Centre Kansas City Kansas USA
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Jazmati D, Brualla L, Littooij AS, Webber B, Dieckmann K, Janssens GO, Simon T, Gaze MN, Merta J, Serrano A, Dietzsch S, Kramer PH, Wulff J, Boterberg T, Timmermann B. Overcoming inter-observer planning variability in target volume contouring and dose planning for high-risk neuroblastoma - a European multicenter effort of the SIOPEN radiotherapy committee. Radiother Oncol 2023; 181:109464. [PMID: 36640946 DOI: 10.1016/j.radonc.2023.109464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 12/26/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE To establish an international quality standard for contouring and planning for high-risk neuroblastoma within the prospective High-Risk Neuroblastoma Study 2 of SIOP-Europe-Neuroblastoma (SIOPEN HR-NBL2), which includes a randomized question on dose escalation for residual disease. MATERIALS AND METHODS Data on four patients with high-risk neuroblastoma were selected and distributed to the radiotherapy committee of the HR-NBL2 study for independent contouring and planning. Differences in contouring were analyzed using apparent and kappa-corrected agreement. Plans were analyzed regarding the dose-volume histogram metrics. Results were discussed among experts and agreement was obtained. RESULTS Substantial agreement was found for contouring of the heart (0.64), liver (0.70), left lung (0.74), and right lung (0.74). For contouring of the gastrointestinal tract (0.54), left kidney (0.60), and right kidney (0.59) moderate agreement was obtained. For target volume delineation, agreement for preoperative tumour extent was moderate (0.42), for CTV fair (0.35) and only low (0.06) for residual tumour, respectively. The dose planning strategies appeared to be relatively homogeneous among all experts. CONCLUSION Considerable variability was found for the delineation of target volumes, particularly the boost volume, whereas the contouring of the organs at risk and the planning strategy were reasonably consistent. In order to obtain reliable results from the randomized HR-NBL2 trial, standardization of target volume delineation based on adequate imaging is crucial.
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Affiliation(s)
- Danny Jazmati
- Department of Particle Therapy, University Hospital Essen, Germany; West German Proton Therapy Centre Essen (WPE), Germany; West German Cancer Center (WTZ), Germany.
| | - Lorenzo Brualla
- West German Proton Therapy Centre Essen (WPE), Germany; West German Cancer Center (WTZ), Germany; Faculty of Medicine, University of Duisburg-Essen, Germany
| | - Annemieke S Littooij
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands., the Netherlands; Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands.
| | - Britta Webber
- Danish Centre of Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Karin Dieckmann
- Department of Radio-Oncology, Medical University of Vienna, Vienna, Austria
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center Utrecht, and Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands; Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Thorsten Simon
- Pediatric Oncology and Hematology, University of Cologne, Cologne, Germany
| | - Mark N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Julien Merta
- Department of Particle Therapy, University Hospital Essen, Germany; West German Proton Therapy Centre Essen (WPE), Germany
| | | | - Stefan Dietzsch
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany
| | - Paul-Heinz Kramer
- West German Proton Therapy Centre Essen (WPE), Germany; West German Cancer Center (WTZ), Germany
| | - Jörg Wulff
- West German Proton Therapy Centre Essen (WPE), Germany; West German Cancer Center (WTZ), Germany
| | - Tom Boterberg
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, Germany; West German Proton Therapy Centre Essen (WPE), Germany; West German Cancer Center (WTZ), Germany; German Cancer Consortium (DKTK), Germany
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Kamrava M, Leung E, Bachand F, Beriwal S, Chargari C, D'Souza D, Erickson B, Fokdal L, Han K, Harkenrider M, Lin L, Mahantshetty U, Nesvacil N, Ravi A, Schmid M, Vigneault E, Westerveld H, Yashar C, Nout R. GEC-ESTRO (ACROP)-ABS-CBG Consensus Brachytherapy Target Definition Guidelines for Recurrent Endometrial and Cervical Tumors in the Vagina. Int J Radiat Oncol Biol Phys 2023; 115:654-663. [PMID: 36191741 DOI: 10.1016/j.ijrobp.2022.09.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/23/2022] [Accepted: 09/13/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Representatives from the Gynecologic Groupe European de Curietherapie-European Society for Radiation Therapy and Oncology (GYN GEC-ESTRO), the American Brachytherapy Society (ABS), and the Canadian Brachytherapy Group (CBG) met to develop international consensus recommendations for target definitions for image-guided adaptive brachytherapy for vaginal recurrences of endometrial or cervical cancer. METHODS AND MATERIALS Seventeen radiation oncologists and 2 medical physicists participated. Before an in-person meeting each participant anonymously contoured 3 recurrent endometrial/cervical cancer cases. Participants contoured the residual gross primary tumor volume (GTV-Tres), a high-risk clinical target volume (CTV-THR), and an intermediate-risk clinical target volume (CTV-TIR), on T2-weighted magnetic resonance images (MRIs). All contours were drawn using Falcon EduCase. Contours were reviewed at an in-person meeting during which a consensus document was created defining agreed-upon target definitions (Trial 1). After establishing these definitions, the group was sent one of the cases again (recurrent cervical cancer vaginal recurrence) and asked to contour the targets again (Trial 2). The Computerized Environment for Radiation Research (CERR) software (The Mathworks, Natwick, MA) was used to analyze the contours. Kappa statistics were generated to assess level of agreement between contours. A conformity index (CI), defined as the ratio between the intersection and union volume of a given pair of contours, was calculated. A simultaneous truth and performance level estimation (STAPLE) contour was created for the CTV-THR and CTV-TIR for the postmeeting case. RESULTS Consensus definitions for GTV-Tres, CTV-THR, and CTV-TIR were established. Kappa statistics (Trial 1/Trial 2) for GTV-Tres, CTV-THR, and CTV-TIR were 0.536/0.583, 0.575/0.743 and 0.522/0.707. Kappa statistics for Trial 2 for the CTV-THR and CTV-TIR showed "substantial" agreement while the GTV-Tres remained at moderate agreement. CONCLUSIONS This consensus provides recommendations to facilitate future collaborations for MRI-guided adaptive brachytherapy target definitions in endometrial/cervical vaginal recurrences.
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Affiliation(s)
| | - Eric Leung
- Sunnybrook Odette Cancer Center, Ontario
| | | | - Sushil Beriwal
- Allegheny Health Network, Pittsburgh, Pennsylvania and Varian Medical Systems, Palo Alto, California
| | - Cyrus Chargari
- Gustave Roussy Comprehensive Cancer Center, Villejuif, France
| | | | | | | | - Kathy Han
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Ontario, Canada
| | | | - Lilie Lin
- MD Anderson Cancer Center, Houston, Texas
| | | | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | | | - Max Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Eric Vigneault
- Centre Hospitalier Universitaire de Québec, Quebec, Canada
| | | | | | - Remi Nout
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
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Kuhara A, Sumi A, Chikasue T, Kawaguchi A, Tanoue S, Nagata S, Koganemaru M, Abe T, Kashihara M, Mitsuoka M, Ishii H, Ohshima K, Leung ANC, Fujimoto K. Utility of non-contrast-enhanced magnetic resonance imaging in predicting preoperative clinical stage and prognosis in patients with thymic epithelial tumor. Jpn J Radiol 2023; 41:302-311. [PMID: 36374474 PMCID: PMC9974725 DOI: 10.1007/s11604-022-01358-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 10/30/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of this study was to find useful imaging features on non-contrast-enhanced magnetic resonance imaging (MRI) that can divide patients with thymic epithelial tumor (TET) into clinical stage I-II and III-IV groups under assumption that contrast media are contraindicated. MATERIALS AND METHODS This retrospective study included 106 patients (median age, 60 years; range, 27-82 years; 62 women) with surgically resected TET who underwent MRI between August 1986 and July 2015. All cases were classified according to the 2015 WHO classification and staged using the eighth edition of the TNM system. Two radiologists independently evaluated 14 categories of MRI findings; the findings in patients with stage I-II were compared with those of patients with stage III-IV using a logistic regression model. Disease-specific survival associated with significant findings was calculated using the Kaplan-Meier method. RESULTS Univariate analysis showed that stage III-IV patients were more likely to have tumors with an irregular contour, heterogeneity on T1WI, low-signal intensity on T2WI, irregular border with lung, findings of great vessel invasion (GVI) (hereafter, GVI sign), pericardial thickening/nodule, and lymphadenopathy (all, P < 0.01). On multivariable analysis, only two findings, irregular border between tumor and lung (odds ratio [OR], 272.8; 95% CI 26.6-2794.1; P < 0.001) and positive GVI sign (OR, 49.3; 95% CI 4.5-539.8; P = 0.001) remained statistically significant. Patients with one or both features had significantly worse survival (log-rank test, P < 0.001). CONCLUSION For patients with TET who are unable to receive contrast for preoperative staging, the two image findings of an irregular border between tumor and lung and the positive GVI sign on non-contrast-enhanced MRI could be helpful in determining stage III-IV disease which is associated with a worse survival.
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Affiliation(s)
- Asako Kuhara
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Akiko Sumi
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Tomonori Chikasue
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Atsushi Kawaguchi
- Education and Research Center for Community Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Shuichi Tanoue
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Shuji Nagata
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Masamichi Koganemaru
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Toshi Abe
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Masaki Kashihara
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Masahiro Mitsuoka
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Hidenobu Ishii
- Division of Respirology, Neurology, and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Koichi Ohshima
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Ann N. C. Leung
- Department of Radiology, Stanford University, Stanford, CA USA
| | - Kiminori Fujimoto
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011, Japan.
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Cheon W, Jeong S, Jeong JH, Lim YK, Shin D, Lee SB, Lee DY, Lee SU, Suh YG, Moon SH, Kim TH, Kim H. Interobserver Variability Prediction of Primary Gross Tumor in a Patient with Non-Small Cell Lung Cancer. Cancers (Basel) 2022; 14:cancers14235893. [PMID: 36497374 PMCID: PMC9741368 DOI: 10.3390/cancers14235893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/25/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
This research addresses the problem of interobserver variability (IOV), in which different oncologists manually delineate varying primary gross tumor volume (pGTV) contours, adding risk to targeted radiation treatments. Thus, a method of IOV reduction is urgently needed. Hypothesizing that the radiation oncologist’s IOV may shrink with the aid of IOV maps, we propose IOV prediction network (IOV-Net), a deep-learning model that uses the fuzzy membership function to produce high-quality maps based on computed tomography (CT) images. To test the prediction accuracy, a ground-truth pGTV IOV map was created using the manual contour delineations of radiation therapy structures provided by five expert oncologists. Then, we tasked IOV-Net with producing a map of its own. The mean squared error (prediction vs. ground truth) and its standard deviation were 0.0038 and 0.0005, respectively. To test the clinical feasibility of our method, CT images were divided into two groups, and oncologists from our institution created manual contours with and without IOV map guidance. The Dice similarity coefficient and Jaccard index increased by ~6 and 7%, respectively, and the Hausdorff distance decreased by 2.5 mm, indicating a statistically significant IOV reduction (p < 0.05). Hence, IOV-net and its resultant IOV maps have the potential to improve radiation therapy efficacy worldwide.
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Kim M, Park B, Kim H, Kim YJ, Choi DJ, Chung W, Kim YJ, Shin HS, Im JH, Suh CO, Kim JH, Ha B, Kim MY, Park J, Lee J, Ahn SJ, Lee SY, Kusumawidjaja G, Lim F, Cho WK, Kim H, Choi DH, Park W. Dummy run quality assurance study in the Korean Radiation Oncology Group 19 − 09 multi-institutional prospective cohort study of breast cancer. Radiat Oncol 2022; 17:186. [PMID: 36384804 PMCID: PMC9670516 DOI: 10.1186/s13014-022-02140-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/02/2022] [Accepted: 10/05/2022] [Indexed: 11/17/2022] Open
Abstract
Background The Korean Radiation Oncology Group (KROG) 19 − 09 prospective cohort study aims to determine the effect of regional nodal irradiation on regional recurrence rates in ypN0 breast cancer patients. Dosimetric variations between radiotherapy (RT) plans of participating institutions may affect the clinical outcome of the study. We performed this study to assess inter-institutional dosimetric variations by dummy run. Methods Twelve participating institutions created RT plans for four clinical scenarios using computed tomography images of two dummy cases. Based on a reference structure set, we analyzed dose-volume histograms after collecting the RT plans. Results We found variations in dose distribution between institutions, especially in the regional nodal areas. Whole breast and regional nodal irradiation (WBI + RNI) plans had lower inter-institutional agreement and similarity for 95% isodose lines than WBI plans. Fleiss’s kappa values, which were used to measure inter-institutional agreement for the 95% isodose lines, were 0.830 and 0.767 for the large and medium breast WBI plans, respectively, and 0.731 and 0.679 for the large and medium breast WBI + RNI plans, respectively. There were outliers in minimum dose delivered to 95% of the structure (D95%) of axillary level 1 among WBI plans and in D95% of the interpectoral region and axillary level 4 among WBI + RNI plans. Conclusion We found inter-institutional and inter-case variations in radiation dose delivered to target volumes and organs at risk. As KROG 19 − 09 is a prospective cohort study, we accepted the dosimetric variation among the different institutions. Actual patient RT plan data should be collected to achieve reliable KROG 19 − 09 study results.
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Variation in clinical target volume delineation in postoperative radiotherapy for biliary tract cancer. PLoS One 2022; 17:e0273395. [PMID: 36048817 PMCID: PMC9436049 DOI: 10.1371/journal.pone.0273395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 08/09/2022] [Indexed: 11/19/2022] Open
Abstract
We aimed to evaluate the inter-clinician variability in the clinical target volume (CTV) for postoperative radiotherapy (PORT) for biliary tract cancer (BTC) including extrahepatic bile duct cancer (EBDC) and gallbladder cancer (GBC). Nine experienced radiation oncologists delineated PORT CTVs for distal EBDC (pT2N1), proximal EBDC (pT2bN1) and GBC (pT2bN1) patients. The expectation maximization algorithm for Simultaneous Truth and Performance Level Estimation (STAPLE) was used to quantify expert agreements. We generated volumes with a confidence level of 80% to compare the maximum distance to each CTV in six directions. The degree of agreement was moderate; overall kappa values were 0.573 for distal EBDC, 0.513 for proximal EBDC, and 0.511 for GBC. In the distal EBDC, a larger variation was noted in the right, post, and inferior direction. In the proximal EBDC, all borders except the right and left direction showed a larger variation. In the GBC, a larger variation was found in the anterior, posterior, and inferior direction. The posterior and inferior borders were the common area having discrepancies, associated with the insufficient coverage of the paraaortic node. A consensus guideline is needed to reduce inter-clinician variability in the CTVs and adequate coverage of regional lymph node area.
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Delineation uncertainties of tumour volumes on MRI of head and neck cancer patients. Clin Transl Radiat Oncol 2022; 36:121-126. [PMID: 36017132 PMCID: PMC9395751 DOI: 10.1016/j.ctro.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/31/2022] [Accepted: 08/04/2022] [Indexed: 11/28/2022] Open
Abstract
Role of target delineation uncertainties in head and neck cancer patients. Knowing contouring variations for MRI allows better adaptation of MRLinac for H&N cancers. An interobserver variation for GTV among 8 observers was below 2 mm using MRI. Variability between observers might improve using other imaging modalities.
Background During the last decade, radiotherapy using MR Linac has gone from research to clinical implementation for different cancer locations. For head and neck cancer (HNC), target delineation based only on MR images is not yet standard, and the utilisation of MRI instead of PET/CT in radiotherapy planning is not well established. We aimed to analyse the inter-observer variation (IOV) in delineating GTV (gross tumour volume) on MR images only for patients with HNC. Material/methods 32 HNC patients from two independent departments were included. Four clinical oncologists from Denmark and four radiation oncologists from Australia had independently contoured primary tumour GTVs (GTV-T) and nodal GTVs (GTV-N) on T2-weighted MR images obtained at the time of treatment planning. Observers were provided with sets of images, delineation guidelines and patient synopsis. Simultaneous truth and performance level estimation (STAPLE) reference volumes were generated for each structure using all observer contours. The IOV was assessed using the DICE Similarity Coefficient (DSC) and mean absolute surface distance (MASD). Results 32 GTV-Ts and 68 GTV-Ns were contoured per observer. The median MASD for GTV-Ts and GTV-Ns across all patients was 0.17 cm (range 0.08–0.39 cm) and 0.07 cm (range 0.04–0.33 cm), respectively. Median DSC relative to a STAPLE volume for GTV-Ts and GTV-Ns across all patients were 0.73 and 0.76, respectively. A significant correlation was seen between median DSCs and median volumes of GTV-Ts (Spearman correlation coefficient 0.76, p < 0.001) and of GTV-Ns (Spearman correlation coefficient 0.55, p < 0.001). Conclusion Contouring GTVs in patients with HNC on MRI showed that the median IOV for GTV-T and GTV-N was below 2 mm, based on observes from two separate radiation departments. However, there are still specific regions in tumours that are difficult to resolve as either malignant tissue or oedema that potentially could be improved by further training in MR-only delineation.
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Dosimetric impact of interfraction prostate and seminal vesicle volume changes and rotation: A post-hoc analysis of a phase III randomized trial of MRI-guided versus CT-guided stereotactic body radiotherapy. Radiother Oncol 2021; 167:203-210. [PMID: 34979212 DOI: 10.1016/j.radonc.2021.12.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/10/2021] [Accepted: 12/24/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE Interfraction volumetric changes/rotations in the prostate and proximal seminal vesicles (SVs) might compromise target coverage when tight margins are used for prostate stereotactic body radiotherapy (SBRT). We investigated on-board MRI images from MRI-guided SBRT to better understand this. MATERIALS AND METHODS Twenty consecutive patients treated with MRI-guided prostate SBRT (40 Gy/5 fractions) enrolled on the MRI arm of a phase III randomized trial were included. A 2 mm isotropic margin was used for prostate and proximal SVPTV. Target volume, prostate dimensions, angles of the proximal SV on axial (angle α) and sagittal view (angle θ) were measured on a 0.35 T simulation MRI and five on-board pre-treatment MRIs. Dice coefficient of the targets and target dosimetry were calculated. RESULTS All patients experienced an isotropic increase in prostate volume during SBRT (p = 0.0016): 0.1%, 9.0%, 12.1%, 15.1%, and 14.2% (median) at fractions 1-5, respectively, regardless of baseline volume, which was significantly reduced with neoadjuvant ADT (p = 0.0042). There was minimal interfraction rotation of prostate, however, considerable variations in proximal SV angle α (median 21.5°) and angle θ (median 17.6°) were seen. Median V100% was 97.5% and 87.1% for prostate and proximal SV CTV, respectively. V95%≥95% was achieved in 94% of fractions for the prostate and in 59% for proximal SV. CONCLUSION Prostate volume consistently increased during SBRT. Interfraction prostatic rotation was minimal while rotation of the proximal SV was considerable. Prostate dosimetry was favorable, but online adaptive therapy may be indicated occasionally to account for prostatic swelling and in particular proximal SV rotations.
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Vaassen F, Hazelaar C, Canters R, Peeters S, Petit S, van Elmpt W. The impact of organ-at-risk contour variations on automatically generated treatment plans for NSCLC. Radiother Oncol 2021; 163:136-142. [PMID: 34461185 DOI: 10.1016/j.radonc.2021.08.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/29/2021] [Accepted: 08/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE Quality of automatic contouring is generally assessed by comparison with manual delineations, but the effect of contour differences on the resulting dose distribution remains unknown. This study evaluated dosimetric differences between treatment plans optimized using various organ-at-risk (OAR) contouring methods. MATERIALS AND METHODS OARs of twenty lung cancer patients were manually and automatically contoured, after which user-adjustments were made. For each contour set, an automated treatment plan was generated. The dosimetric effect of intra-observer contour variation and the influence of contour variations on treatment plan evaluation and generation were studied using dose-volume histogram (DVH)-parameters for thoracic OARs. RESULTS Dosimetric effect of intra-observer contour variability was highest for Heart Dmax (3.4 ± 6.8 Gy) and lowest for Lungs-GTV Dmean (0.3 ± 0.4 Gy). The effect of contour variation on treatment plan evaluation was highest for Heart Dmax (6.0 ± 13.4 Gy) and Esophagus Dmax (8.7 ± 17.2 Gy). Dose differences for the various treatment plans, evaluated on the reference (manual) contour, were on average below 1 Gy/1%. For Heart Dmean, higher dose differences were found for overlap with PTV (median 0.2 Gy, 95% 1.7 Gy) vs. no PTV overlap (median 0 Gy, 95% 0.5 Gy). For Dmax-parameters, largest dose difference was found between 0-1 cm distance to PTV (median 1.5 Gy, 95% 4.7 Gy). CONCLUSION Dose differences arising from automatic contour variations were of the same magnitude or lower than intra-observer contour variability. For Heart Dmean, we recommend delineation errors to be corrected when the heart overlaps with the PTV. For Dmax-parameters, we recommend checking contours if the distance is close to PTV (<5 cm). For the lungs, only obvious large errors need to be adjusted.
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Affiliation(s)
- Femke Vaassen
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - Colien Hazelaar
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Richard Canters
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Stephanie Peeters
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Steven Petit
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
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Leonardi MC, Pepa M, Gugliandolo SG, Luraschi R, Vigorito S, Rojas DP, La Porta MR, Cante D, Petrucci E, Marino L, Borzì G, Ippolito E, Marrocco M, Huscher A, Chieregato M, Argenone A, Iadanza L, De Rose F, Lobefalo F, Cucciarelli F, Valenti M, De Santis MC, Cavallo A, Rossi F, Russo S, Prisco A, Guernieri M, Guarnaccia R, Malatesta T, Meaglia I, Liotta M, Tabarelli de Fatis P, Palumbo I, Marcantonini M, Colangione SP, Mezzenga E, Falivene S, Mormile M, Ravo V, Arrichiello C, Fozza A, Barbero MP, Ivaldi GB, Catalano G, Vidali C, Aristei C, Giannitto C, Miglietta E, Ciabattoni A, Meattini I, Orecchia R, Cattani F, Jereczek-Fossa BA. Geometric contour variation in clinical target volume of axillary lymph nodes in breast cancer radiotherapy: an AIRO multi-institutional study. Br J Radiol 2021; 94:20201177. [PMID: 33882239 PMCID: PMC8248216 DOI: 10.1259/bjr.20201177] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/23/2020] [Accepted: 01/25/2021] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To determine interobserver variability in axillary nodal contouring in breast cancer (BC) radiotherapy (RT) by comparing the clinical target volume of participating single centres (SC-CTV) with a gold-standard CTV (GS-CTV). METHODS The GS-CTV of three patients (P1, P2, P3) with increasing complexity was created in DICOM format from the median contour of axillary CTVs drawn by BC experts, validated using the simultaneous truth and performance-level estimation and peer-reviewed. GS-CTVs were compared with the correspondent SC-CTVs drawn by radiation oncologists, using validated metrics and a total score (TS) integrating all of them. RESULTS Eighteen RT centres participated in the study. Comparative analyses revealed that, on average, the SC-CTVs were smaller than GS-CTV for P1 and P2 (by -29.25% and -27.83%, respectively) and larger for P3 (by +12.53%). The mean Jaccard index was greater for P1 and P2 compared to P3, but the overlap extent value was around 0.50 or less. Regarding nodal levels, L4 showed the highest concordance with the GS. In the intra-patient comparison, L2 and L3 achieved lower TS than L4. Nodal levels showed discrepancy with GS, which was not statistically significant for P1, and negligible for P2, while P3 had the worst agreement. DICE similarity coefficient did not exceed the minimum threshold for agreement of 0.70 in all the measurements. CONCLUSIONS Substantial differences were observed between SC- and GS-CTV, especially for P3 with altered arm setup. L2 and L3 were the most critical levels. The study highlighted these key points to address. ADVANCES IN KNOWLEDGE The present study compares, by means of validated geometric indexes, manual segmentations of axillary lymph nodes in breast cancer from different observers and different institutions made on radiotherapy planning CT images. Assessing such variability is of paramount importance, as geometric uncertainties might lead to incorrect dosimetry and compromise oncological outcome.
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Affiliation(s)
| | - Matteo Pepa
- Division of Radiation Oncology, IEO Istituto Europeo di Oncologia IRCCS, Milano, Italy
| | | | - Rosa Luraschi
- Unit of Medical Physics, IEO Istituto Europeo di Oncologia IRCCS, Milano, Italy
| | - Sabrina Vigorito
- Unit of Medical Physics, IEO Istituto Europeo di Oncologia IRCCS, Milano, Italy
| | | | | | - Domenico Cante
- Radiotherapy Department, ASL TO4 Ivrea Community Hospital, Ivrea, Italy
| | - Edoardo Petrucci
- Unit of Medical Physics, ASL TO4 Ivrea Community Hospital, Ivrea, Italy
| | - Lorenza Marino
- Radiotherapy Unit, REM Radioterapia, Viagrande (CT), Italy
| | - Giuseppina Borzì
- Unit of Medical Physics, REM Radioterapia, Viagrande (CT), Italy
| | - Edy Ippolito
- Department of Radiotherapy, Campus Bio-Medico University, Roma, Italy
| | | | | | | | - Angela Argenone
- Division of Radiation Oncology, Azienda Ospedaliera di Rilievo Nazionale San Pio, Benevento, Italy
| | - Luciano Iadanza
- Unit of Medical Physics, Azienda Ospedaliera di Rilievo Nazionale San Pio, Benevento, italy
| | - Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Centre IRCCS, Milano, Italy
| | - Francesca Lobefalo
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Centre IRCCS, Milano, Italy
| | - Francesca Cucciarelli
- Department of Internal Medicine, Radiotherapy Institute, Ospedali Riuniti Umberto I, G.M. Lancisi, G. Salesi, Ancona, Italy
| | - Marco Valenti
- Unit of Medical Physics, Ospedali Riuniti Umberto I, G.M. Lancisi, G. Salesi, Ancona, Italy
| | | | - Anna Cavallo
- Unit of Medical Physics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Francesca Rossi
- Radiotherapy Unit, Usl Toscana Centro, Ospedale Santa Maria Annunziata, Firenze, Italy
| | - Serenella Russo
- Unit of Medical Physics, Usl Toscana Centro, Ospedale Santa Maria Annunziata, Firenze, Italy
| | - Agnese Prisco
- Department of Radiotherapy, ASUFC - P.O. “ Santa Maria della Misericordia” di Udine, Udine, Italy
| | - Marika Guernieri
- Unit of Medical Physics, ASUFC - P.O. “ Santa Maria della Misericordia” di Udine, Udine, Italy
| | - Roberta Guarnaccia
- Radiotherapy Unit, Ospedale Fatebenefratelli Isola Tiberina, Roma, Italy
| | - Tiziana Malatesta
- Unit of Medical Physics, Ospedale Fatebenefratelli Isola Tiberina, Roma, Italy
| | - Ilaria Meaglia
- Radiation Oncology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Marco Liotta
- Medical Physics Unit, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | | | - Isabella Palumbo
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | | | - Sarah Pia Colangione
- Radiotherapy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Emilio Mezzenga
- Medical Physics Unit, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) "Dino Amadori", Meldola (FC), Italy
| | - Sara Falivene
- Department of Radiotherapy, ASL Napoli 1 Centro - Ospedale del Mare, Napoli, Italy
| | - Maria Mormile
- Unit of Medical Physics, ASL Napoli 1 Centro - Ospedale del Mare, Napoli, Italy
| | - Vincenzo Ravo
- Unit of Radiotherapy, Istituto Nazionale Tumori – IRCCS - Fondazione G. Pascale, Napoli, Italy
| | - Cecilia Arrichiello
- Unit of Radiotherapy, Istituto Nazionale Tumori – IRCCS - Fondazione G. Pascale, Napoli, Italy
| | - Alessandra Fozza
- Division of Radiation Oncology, Azienda Ospedaliera Nazionale SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Maria Paola Barbero
- Unit of Medical Physics, Azienda Ospedaliera Nazionale SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | | | - Gianpiero Catalano
- Department of Radiotherapy, IRCCS MultiMedica, Sesto San Giovanni (MI), Italy
| | - Cristiana Vidali
- Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata di Trieste (ASUI-TS), Trieste, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Caterina Giannitto
- Division of Radiology, IEO Istituto Europeo di Oncologia IRCCS, Milano, Italy
| | - Eleonora Miglietta
- Division of Radiation Oncology, IEO Istituto Europeo di Oncologia IRCCS, Milano, Italy
| | | | | | - Roberto Orecchia
- Scientific Direction, IEO Istituto Europeo di Oncologia IRCCS, Milano, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO Istituto Europeo di Oncologia IRCCS, Milano, Italy
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Cao M, Gao Y, Yoon SM, Yang Y, Sheng K, Ballas LK, Basehart V, Sachdeva A, Felix C, Low DA, Steinberg ML, Kishan AU. Interfractional Geometric Variations and Dosimetric Benefits of Stereotactic MRI Guided Online Adaptive Radiotherapy (SMART) of Prostate Bed after Radical Prostatectomy: Post-Hoc Analysis of a Phase II Trial. Cancers (Basel) 2021; 13:cancers13112802. [PMID: 34199881 PMCID: PMC8200117 DOI: 10.3390/cancers13112802] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To evaluate geometric variations of patients receiving stereotactic body radiotherapy (SBRT) after radical prostatectomy and the dosimetric benefits of stereotactic MRI guided adaptive radiotherapy (SMART) to compensate for these variations. MATERIALS/METHODS The CTV and OAR were contoured on 55 MRI setup scans of 11 patients treated with an MR-LINAC and enrolled in a phase II trial of post-prostatectomy SBRT. All patients followed institutional bladder and rectum preparation protocols and received five fractions of 6-6.8 Gy to the prostate bed. Interfractional changes in volume were calculated and shape deformation was quantified by the Dice similar coefficient (DSC). Changes in CTV-V95%, bladder and rectum maximum dose, V32.5Gy and V27.5Gy were predicted by recalculating the initial plan on daily MRI. SMART was retrospectively simulated if the predicted dose exceeded pre-set criteria. RESULTS The CTV volume and shape remained stable with a median volumetric change of 3.0% (IQR -3.0% to 11.5%) and DSC of 0.83 (IQR 0.79 to 0.88). Relatively large volumetric changes in bladder (median -24.5%, IQR -34.6% to 14.5%) and rectum (median 5.4%, IQR - 9.7% to 20.7%) were observed while shape changes were moderate (median DSC of 0.79 and 0.73, respectively). The median CTV-V95% was 98.4% (IQR 94.9% to 99.6%) for the predicted doses. However, SMART would have been deemed beneficial for 78.2% of the 55 fractions based on target undercoverage (16.4%), exceeding OAR constraints (50.9%), or both (10.9%). Simulated SMART improved the dosimetry and met dosimetric criteria in all fractions. Moderate correlations were observed between the CTV-V95% and target DSC (R2 = 0.73) and bladder mean dose versus volumetric changes (R2 = 0.61). CONCLUSIONS Interfractional dosimetric variations resulting from anatomic deformation are commonly encountered with post-prostatectomy RT and can be mitigated with SMART.
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Affiliation(s)
- Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (Y.G.); (S.M.Y.); (Y.Y.); (K.S.); (V.B.); (A.S.); (C.F.); (D.A.L.); (M.L.S.); (A.U.K.)
- Correspondence:
| | - Yu Gao
- Department of Radiation Oncology, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (Y.G.); (S.M.Y.); (Y.Y.); (K.S.); (V.B.); (A.S.); (C.F.); (D.A.L.); (M.L.S.); (A.U.K.)
| | - Stephanie M. Yoon
- Department of Radiation Oncology, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (Y.G.); (S.M.Y.); (Y.Y.); (K.S.); (V.B.); (A.S.); (C.F.); (D.A.L.); (M.L.S.); (A.U.K.)
| | - Yingli Yang
- Department of Radiation Oncology, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (Y.G.); (S.M.Y.); (Y.Y.); (K.S.); (V.B.); (A.S.); (C.F.); (D.A.L.); (M.L.S.); (A.U.K.)
| | - Ke Sheng
- Department of Radiation Oncology, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (Y.G.); (S.M.Y.); (Y.Y.); (K.S.); (V.B.); (A.S.); (C.F.); (D.A.L.); (M.L.S.); (A.U.K.)
| | - Leslie K. Ballas
- Department of Radiation Oncology, University of Southern California, Los Angeles, CA 90089, USA;
| | - Vincent Basehart
- Department of Radiation Oncology, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (Y.G.); (S.M.Y.); (Y.Y.); (K.S.); (V.B.); (A.S.); (C.F.); (D.A.L.); (M.L.S.); (A.U.K.)
| | - Ankush Sachdeva
- Department of Radiation Oncology, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (Y.G.); (S.M.Y.); (Y.Y.); (K.S.); (V.B.); (A.S.); (C.F.); (D.A.L.); (M.L.S.); (A.U.K.)
| | - Carol Felix
- Department of Radiation Oncology, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (Y.G.); (S.M.Y.); (Y.Y.); (K.S.); (V.B.); (A.S.); (C.F.); (D.A.L.); (M.L.S.); (A.U.K.)
| | - Daniel A. Low
- Department of Radiation Oncology, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (Y.G.); (S.M.Y.); (Y.Y.); (K.S.); (V.B.); (A.S.); (C.F.); (D.A.L.); (M.L.S.); (A.U.K.)
| | - Michael L. Steinberg
- Department of Radiation Oncology, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (Y.G.); (S.M.Y.); (Y.Y.); (K.S.); (V.B.); (A.S.); (C.F.); (D.A.L.); (M.L.S.); (A.U.K.)
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA; (Y.G.); (S.M.Y.); (Y.Y.); (K.S.); (V.B.); (A.S.); (C.F.); (D.A.L.); (M.L.S.); (A.U.K.)
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Lawrence LSP, Chin LCL, Chan RW, Nguyen TK, Sahgal A, Tseng CL, Lau AZ. Method of computing direction-dependent margins for the development of consensus contouring guidelines. Radiat Oncol 2021; 16:71. [PMID: 33849576 PMCID: PMC8045331 DOI: 10.1186/s13014-021-01799-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/31/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Clinical target volume (CTV) contouring guidelines are frequently developed through studies in which experts contour the CTV for a representative set of cases for a given treatment site and the consensus CTVs are analyzed to generate margin recommendations. Measures of interobserver variability are used to quantify agreement between experts. In cases where an isotropic margin is not appropriate, however, there is no standard method to compute margins in specified directions that represent possible routes of tumor spread. Moreover, interobserver variability metrics are often measures of volume overlap that do not account for the dependence of disagreement on direction. To aid in the development of consensus contouring guidelines, this study demonstrates a novel method of quantifying CTV margins and interobserver variability in clinician-specified directions. METHODS The proposed algorithm was applied to 11 cases of non-spine bone metastases to compute the consensus CTV margin in each direction of intraosseous and extraosseous disease. The median over all cases for each route of spread yielded the recommended margins. The disagreement between experts on the CTV margin was quantified by computing the median of the coefficients of variation for intraosseous and extraosseous margins. RESULTS The recommended intraosseous and extraosseous margins were 7.0 mm and 8.0 mm, respectively. The median coefficient of variation quantifying the margin disagreement between experts was 0.59 and 0.48 for intraosseous and extraosseous disease. CONCLUSIONS The proposed algorithm permits the generation of margin recommendations in relation to adjacent anatomy and quantifies interobserver variability in specified directions. This method can be applied to future consensus CTV contouring studies.
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Affiliation(s)
- Liam S P Lawrence
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Lee C L Chin
- Department of Medical Physics, Odette Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachel W Chan
- Physical Sciences Platform, Sunnybrook Research Institute, 2075 Bayview Ave., Toronto, M4N 3M5, ON, Canada
| | - Timothy K Nguyen
- Department of Radiation Oncology, London Health Sciences Centre, Western University, London, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Angus Z Lau
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada. .,Physical Sciences Platform, Sunnybrook Research Institute, 2075 Bayview Ave., Toronto, M4N 3M5, ON, Canada.
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Kim KS, Cheong KH, Kim K, Koo T, Koh HK, Chang JH, Chang AR, Park HJ. Interobserver variability in clinical target volume delineation in anal squamous cell carcinoma. Sci Rep 2021; 11:2785. [PMID: 33531643 PMCID: PMC7854655 DOI: 10.1038/s41598-021-82541-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 01/20/2021] [Indexed: 12/24/2022] Open
Abstract
We evaluated the inter-physician variability in the target contouring of the radiotherapy for anal squamous cell carcinoma (ASCC). Clinical target volume (CTV) of three patients diagnosed with ASCC was delineated by seven experienced radiation oncologists from multi-institution. These patients were staged as pT1N1a, cT2N0, and cT4N1a, respectively, according to 8th edition of the American Joint Committee on Cancer staging system. Expert agreement was quantified using an expectation maximization algorithm for Simultaneous Truth and Performance Level Estimation (STAPLE). The maximum distance from the boundaries of the STAPLE generated volume with confidence level of 80% to those of the contour of each CTV in 6 directions was compared. CTV of pelvis which includes primary tumor, perirectal tissue and internal/external iliac lymph node (LN) area (CTV-pelvis) and CTV of inguinal area (CTV-inguinal) were obtained from the seven radiation oncologists. One radiation oncologist did not contain inguinal LN area in the treatment target volume of patient 2 (cT2N0 stage). CTV-inguinal displayed moderate agreement for each patient (overall kappa 0.58, 0.54 and 0.6, respectively), whereas CTV-pelvis showed substantial agreement (overall kappa 0.66, 0.68 and 0.64, respectively). Largest variation among each contour was shown in the inferior margin of the CTV-inguinal. For CTV-pelvis, anterior and superior margin showed the biggest variation. Overall, moderate to substantial agreement was shown for CTV delineation. However, large variations in the anterior and cranial boarder of the CTV-pelvis and the caudal margin of the CTV-inguinal suggest that further studies are needed to establish a clearer target volume delineation guideline.
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Affiliation(s)
- Kyung Su Kim
- Department of Radiation Oncology, Dongnam Institute of Radiological and Medical Sciences, Busan, Republic of Korea.,Department of Radiation Oncology, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro Yangcheon-gu, Seoul, 07985, Republic of Korea
| | - Kwang-Ho Cheong
- Department of Radiation Oncology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro Yangcheon-gu, Seoul, 07985, Republic of Korea.
| | - Taeryool Koo
- Department of Radiation Oncology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Hyeon Kang Koh
- Department of Radiation Oncology, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul Metropolitan Government, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Ah Ram Chang
- Department of Radiation Oncology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Hae Jin Park
- Department of Radiation Oncology, Hanyang University College of Medicine, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea.
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Sabater S, Pastor-Juan MR, Andres I, López-Martinez L, Lopez-Honrubia V, Tercero-Azorin MI, Sevillano M, Lozano-Setien E, Jimenez-Jimenez E, Berenguer R, Rovirosa A, Castro-Larefors S, Magdalena Marti-Laosa M, Roche O, Martinez-Terol F, Arenas M. MRI prostate contouring is not impaired by the use of a radiotherapy image acquisition set-up. An intra- and inter-observer paired comparative analysis with diagnostic set-up images. Cancer Radiother 2021; 25:107-113. [PMID: 33423967 DOI: 10.1016/j.canrad.2020.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/09/2020] [Accepted: 05/14/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE The use of MRI for radiotherapy planning purposes is growing but image acquisition using radiotherapy set-ups has impaired image quality. Whether differences in image acquisition set-up could modify organ contouring has not been evaluated. Therefore, we aimed to evaluate differences in contouring between paired of image sets that were acquired in the same scanning session using different parameters. MATERIAL AND METHODS Ten patients underwent RT treatment planning with MRI co-registration. MRI was carried out using two different set-ups during the same session, MRI radiotherapy set-ups and MRI diagnostic set-ups. Prostates and rectums were retrospectively contoured in both image sets by 5 radiation oncologists and 4 radiologists. Intra-observer analysis was carried out comparing organ volumes, the Dice coefficient and hausdorff distance values between two contouring rounds. Inter-observer analysis was carried out by comparing individual contours to a generated STAPLE consensus contour, which is considered the gold standard reference. RESULTS No significant differences were observed between MRI acquisition set-ups. Significant differences were observed for the dice and hausdorff parameters, comparing individual contours to the STAPLE consensus contour, when analysing diagnostic images between rounds, although raw values were similar. CONCLUSION Prostate and rectum contours did not differ significantly when using diagnostic or radiotherapy MRI acquisition set-ups.
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Affiliation(s)
- S Sabater
- Department of radiation oncology, Complejo hospitalario universitario de Albacete (CHUA), C/Hnos Falcó 37, 02006 Albacete, Spain.
| | - M R Pastor-Juan
- Department of radiology, Complejo hospitalario universitario de Albacete (CHUA), Albacete, Spain
| | - I Andres
- Department of radiation oncology, Complejo hospitalario universitario de Albacete (CHUA), C/Hnos Falcó 37, 02006 Albacete, Spain
| | - L López-Martinez
- Department of radiology, Complejo hospitalario universitario de Albacete (CHUA), Albacete, Spain
| | - V Lopez-Honrubia
- Department of radiation oncology, Complejo hospitalario universitario de Albacete (CHUA), C/Hnos Falcó 37, 02006 Albacete, Spain
| | - M I Tercero-Azorin
- Department of radiology, Complejo hospitalario universitario de Albacete (CHUA), Albacete, Spain
| | - M Sevillano
- Department of radiation oncology, Complejo hospitalario universitario de Albacete (CHUA), C/Hnos Falcó 37, 02006 Albacete, Spain
| | - E Lozano-Setien
- Department of radiology, Complejo hospitalario universitario de Albacete (CHUA), Albacete, Spain
| | - E Jimenez-Jimenez
- Department of radiation oncology, hospital universitario Santa Lucia, Cartagena, Spain
| | - R Berenguer
- Department of radiation oncology, Complejo hospitalario universitario de Albacete (CHUA), C/Hnos Falcó 37, 02006 Albacete, Spain
| | - A Rovirosa
- Gynecological cancer unit, radiation oncology department, ICMHO, IDIBAPS, university of Barcelona, hospital clinic, Barcelona, Spain
| | - S Castro-Larefors
- Department of radiation oncology, Complejo hospitalario universitario de Albacete (CHUA), C/Hnos Falcó 37, 02006 Albacete, Spain
| | - M Magdalena Marti-Laosa
- Department of radiation oncology, Complejo hospitalario universitario de Albacete (CHUA), C/Hnos Falcó 37, 02006 Albacete, Spain
| | - O Roche
- Laboratorio de oncología, unidad de medicina molecular, unidad asociada de biomedicina UCLM, unidad asociada al CSIC, centro regional de investigaciones biomédicas, universidad de Castilla-La Mancha, Albacete, Spain; Departamento de ciencias médicas, facultad de medicina de Albacete, universidad de Castilla-La Mancha, Albacete, Spain
| | - F Martinez-Terol
- Complejo hospitalario universitario de Albacete (CHUA), Albacete, Spain
| | - M Arenas
- Department of radiation oncology, hospital universitari Sant Joan, Reus, Spain
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Cho WK, Kim H, Park W, Kim SW, Kim J, Lee KK, Oh JG, Yoon MS, Song JY, Ahn KJ, Park SK, Choi JH, Bak J. A dummy-run evaluation of postoperative hypofractionated intensity-modulated radiation therapy (POHIM-RT) trials for cervical cancer. JOURNAL OF RADIATION RESEARCH 2021; 62:149-154. [PMID: 33392616 PMCID: PMC7779361 DOI: 10.1093/jrr/rraa085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 08/02/2020] [Accepted: 01/20/2020] [Indexed: 05/05/2023]
Abstract
The postoperative hypofractionated intensity-modulated radiation therapy (POHIM-RT) trial is a phase II study to evaluate toxicity following hypofractionated intensity modulated radiation therapy (IMRT) for cervical cancer. This study describes the results of a benchmark procedure for RT quality assurance of the POHIM-RT trial. Six participating institutions were provided computed tomography for RT planning and an IMRT plan for a sample and were instructed to delineate volumes, create a treatment plan and quality assurance (QA) plan, and submit the results of all procedures. The inter-institutional agreements on RT volume and plan results were evaluated using the kappa value and dice similarity coefficients. The simultaneous truth and performance level estimation (STAPLE) method was employed to generate a consensus target volume. The treatment volumes, organs-at-risk volumes, and results of the RT plan and QA reported by the institutions were acceptable and adhered well to the protocol. In terms of clinical target volume (CTV) delineation, there were differences between the institutions, particularly in vaginal cuff and paracolpium subsites. Consensus CTV was generated from the collected CTVs with the STAPLE method. The participating institutions showed considerable agreement regarding volume, dose and QA results. To improve CTV agreement in CTV, we provided feedback with images of the consensus target volume and detailed written guidelines for specific subsites that were the most heterogeneous.
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Affiliation(s)
| | | | - Won Park
- Corresponding author. Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea. Tel: +82-2-3410-2612; Fax: +82-2-3410-2619;
| | - Sang-Won Kim
- Department of Radiation Oncology, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Jongwon Kim
- Department of Radiation Oncology, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Kang Kyu Lee
- Department of Radiation Oncology, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Jeong Geun Oh
- Department of Radiation Oncology, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Mee Sun Yoon
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Ju-Young Song
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Ki Jung Ahn
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Busan, Republic of Korea
| | - Sung Kwang Park
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Busan, Republic of Korea
| | - Jin Hwa Choi
- Department of Radiation Oncology, Chung-Ang University Hospital, Seoul, South Korea
| | - Jino Bak
- Department of Radiation Oncology, Chung-Ang University Hospital, Seoul, South Korea
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21
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Stieb S, Mohamed ASR, He R, Zhu LL, McDonald BA, Wahid K, van Dijk LV, Ventura J, Ahmed S, McCoy L, Deshpande TS, Grant S, Reddy JP, Phan J, Garden AS, Rosenthal DI, Frank SJ, Gunn GB, Fuller CD. Development and validation of a contouring guideline for the taste bud bearing tongue mucosa. Radiother Oncol 2020; 157:63-69. [PMID: 33217499 DOI: 10.1016/j.radonc.2020.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To introduce a contouring guideline for the taste bud bearing tongue mucosa for head and neck cancer patients receiving radiotherapy. METHODS AND MATERIALS CT simulation images of oropharyngeal cancer patients were used to delineate both the whole tongue (extrinsic/intrinsic tongue muscles, floor of mouth) and the taste bud bearing tongue mucosa (method A: adaptation of the whole tongue structure; method B: axial adaptation of a mid-sagittal contour). Volumetric and dosimetric parameters of the whole tongue and the two methods of mucosal delineation, spatial overlap between methods A and B, and inter-observer variability for method B were calculated. RESULTS The study cohort was comprised of 70 patients with T1-4 N0-1 tonsillar (83%) and base of tongue (17%) cancers. Most of the comparative parameters between the whole tongue and mucosa (method A) significantly differed (mean, minimum, and maximum dose, V5-V70, D40-D90). The mean dose calculated for the whole tongue deviated on average 3.77 Gy compared to method A. No significant differences were found between methods A and B of the taste bud bearing tongue mucosa structure, and none of the dosimetric parameters differed more than 1.03 Gy on average. The mean Dice similarity coefficient for both mucosal structures was 0.79 ± 0.05, and 0.63 ± 0.12 for the inter-observer analysis of method B. CONCLUSIONS We defined two methods for delineating the taste bud bearing mucosa and both are equally satisfactory procedures. Either method is preferable over delineation of the whole tongue as organ at risk for taste impairment.
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Affiliation(s)
- Sonja Stieb
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States.
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Renjie He
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Lin L Zhu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Brigid A McDonald
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Kareem Wahid
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Lisanne V van Dijk
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Juan Ventura
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Sara Ahmed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Lance McCoy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Tanaya S Deshpande
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Stephen Grant
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Jay P Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
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22
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Comparison of Dose Distribution in Regional Lymph Nodes in Whole-Breast Radiotherapy vs. Whole-Breast Plus Regional Lymph Node Irradiation: An In Silico Planning Study in Participating Institutions of the Phase III Randomized Trial (KROG 1701). Cancers (Basel) 2020; 12:cancers12113261. [PMID: 33158245 PMCID: PMC7694237 DOI: 10.3390/cancers12113261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 12/03/2022] Open
Abstract
Simple Summary The purpose of the current in silico planning study is to compare radiation doses of whole-breast irradiation (WBI) and whole-breast plus regional lymph node irradiation (WBI+RNI) administered to the regional lymph nodes (RLN) in pN1 breast cancer. Twenty-four participating institutions were asked to create plans of WBI and WBI+RNI for two dummy cases. In all RLN regions including supraclavicular lymph node, axillary lymph node, and internal mammary lymph node, the radiation dose to the RLN was higher in WBI+RNI plan than WBI plan. Abstract The purpose of the current in silico planning study is to compare radiation doses of whole-breast irradiation (WBI) and whole-breast plus regional lymph node irradiation (WBI+RNI) administered to the regional lymph nodes (RLN) in pN1 breast cancer. Twenty-four participating institutions were asked to create plans of WBI and WBI+RNI for two dummy cases. To compare target coverage between the participants, an isodose line equal to 90% of the prescribed dose was converted to an isodose contour (contour90% iso). The relative nodal dose (RND) was obtained using the ratio of RLN dose to the target dose. The Fleiss’s kappa values which represent inter-observer agreement of contour90% iso were over 0.68. For RNI, 6 institutions included axillary lymph node (ALN), supraclavicular lymph node (SCN), and internal mammary lymph node (IMN), while 18 hospitals included only ALN and SCN. The median RND between the WBI and WBI+RNI were as follows: 0.64 vs. 1.05 (ALN level I), 0.27 vs. 1.08 (ALN level II), 0.02 vs. 1.12 (ALN level III), 0.01 vs. 1.12 (SCN), and 0.54 vs. 0.82 (IMN). In all nodal regions, the RND was significantly lower in WBI than in WBI+RNI (p < 0.01). In this study, we could identify the nodal dose difference between WBI and WBI+RNI.
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Glioma consensus contouring recommendations from a MR-Linac International Consortium Research Group and evaluation of a CT-MRI and MRI-only workflow. J Neurooncol 2020; 149:305-314. [PMID: 32860571 PMCID: PMC7541359 DOI: 10.1007/s11060-020-03605-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 08/23/2020] [Indexed: 02/07/2023]
Abstract
Introduction This study proposes contouring recommendations for radiation treatment planning target volumes and organs-at-risk (OARs) for both low grade and high grade gliomas. Methods Ten cases consisting of 5 glioblastomas and 5 grade II or III gliomas, including their respective gross tumor volume (GTV), clinical target volume (CTV), and OARs were each contoured by 6 experienced neuro-radiation oncologists from 5 international institutions. Each case was first contoured using only MRI sequences (MRI-only), and then re-contoured with the addition of a fused planning CT (CT-MRI). The level of agreement among all contours was assessed using simultaneous truth and performance level estimation (STAPLE) with the kappa statistic and Dice similarity coefficient. Results A high level of agreement was observed between the GTV and CTV contours in the MRI-only workflow with a mean kappa of 0.88 and 0.89, respectively, with no statistically significant differences compared to the CT-MRI workflow (p = 0.88 and p = 0.82 for GTV and CTV, respectively). Agreement in cochlea contours improved from a mean kappa of 0.39 to 0.41, to 0.69 to 0.71 with the addition of CT information (p < 0.0001 for both cochleae). Substantial to near perfect level of agreement was observed in all other contoured OARs with a mean kappa range of 0.60 to 0.90 in both MRI-only and CT-MRI workflows. Conclusions Consensus contouring recommendations for low grade and high grade gliomas were established using the results from the consensus STAPLE contours, which will serve as a basis for further study and clinical trials by the MR-Linac Consortium. Electronic supplementary material The online version of this article (10.1007/s11060-020-03605-6) contains supplementary material, which is available to authorized users.
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24
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Shaaer A, Paudel M, Davidson M, Semple M, Nicolae A, Mendez LC, Chung H, Loblaw A, Tseng CL, Morton G, Ravi A. Dosimetric evaluation of MRI-to-ultrasound automated image registration algorithms for prostate brachytherapy. Brachytherapy 2020; 19:599-606. [PMID: 32712028 DOI: 10.1016/j.brachy.2020.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/13/2020] [Accepted: 06/15/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Identifying dominant intraprostatic lesions (DILs) on transrectal ultrasound (TRUS) images during prostate high-dose-rate brachytherapy treatment planning remains a significant challenge. Multiparametric MRI (mpMRI) is the tool of choice for DIL identification; however, the geometry of the prostate on mpMRI and on the TRUS may differ significantly, requiring image registration. This study assesses the dosimetric impact attributed to differences in DIL contours generated using commonly available MRI to TRUS automated registration: rigid, semi-rigid, and deformable image registration, respectively. METHODS AND MATERIALS Ten patients, each with mpMRI and TRUS data sets, were included in this study. Five radiation oncologists with expertise in TRUS-based high-dose-rate brachytherapy were asked cognitively to transfer the DIL from the mpMRI images of each patient to the TRUS image. The contours were analyzed for concordance using simultaneous truth and performance level estimation (STAPLE) algorithm. The impact of DIL contour differences due to registration variability was evaluated by comparing the STAPLE-DIL dosimetry from the reference (STAPLE) plan with that from the evaluation plans (manual and automated registration) for each patient. The dosimetric impact of the automatic registration approach was also validated using a margin expansion that normalizes the volume of the autoregistered DILs to the volumes of the STAPLE-DILs. Dose metrics including D90, Dmean, V150, and V200 to the prostate and DIL were reported. For urethra and rectum, D10 and V80 were reported. RESULTS Significant differences in DIL coverage between reference and evaluation plans were found regardless of the algorithm methodology. No statistical difference was reported in STAPLE-DIL dosimetry when manual registration was used. A margin of 1.5 ± 0.8 mm, 1.1 ± 0.8 mm, and 2.5 ± 1.6 mm was required to be added for rigid, semi-rigid, and deformable registration, respectively, to mitigate the difference in STAPLE-DIL coverage between the evaluation and reference plans. CONCLUSION The dosimetric impact of integrating an MRI-delineated DIL into a TRUS-based brachytherapy workflow has been validated in this study. The results show that rigid, semi-rigid, and deformable registration algorithms lead to a significant undercoverage of the DIL D90 and Dmean. A margin of at least 1.5 ± 0.8 mm, 1.1 ± 0.8 mm, and 2.5 ± 1.6 mm is required to be added to the rigid, semi-rigid, and deformable DIL registration to be suitable for DIL-boosting during prostate brachytherapy.
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Affiliation(s)
- Amani Shaaer
- Department of physics, Ryerson University, Toronto, Ontario, Canada; Biomedical Physics Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Moti Paudel
- Department of Medical Physics, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Melanie Davidson
- Department of Medical Physics, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mark Semple
- Department of Medical Physics, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alexandru Nicolae
- Department of Medical Physics, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lucas Castro Mendez
- Department of Medical Physics, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Hans Chung
- Department of Radiation Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Loblaw
- Department of Radiation Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Gerard Morton
- Department of Radiation Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ananth Ravi
- Department of Medical Physics, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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25
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Lin D, Lapen K, Sherer MV, Kantor J, Zhang Z, Boyce LM, Bosch W, Korenstein D, Gillespie EF. A Systematic Review of Contouring Guidelines in Radiation Oncology: Analysis of Frequency, Methodology, and Delivery of Consensus Recommendations. Int J Radiat Oncol Biol Phys 2020; 107:827-835. [PMID: 32311418 PMCID: PMC8262136 DOI: 10.1016/j.ijrobp.2020.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/05/2020] [Accepted: 04/08/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Clinical trials have described variation in radiation therapy plan quality, of which contour delineation is a key component, and linked this to inferior patient outcomes. In response, consensus guidelines have been developed to standardize contour delineation. This investigation assesses trends in contouring guidelines and examines the methodologies used to generate and deliver recommendations. METHODS AND MATERIALS We conducted a literature search for contouring guidelines published after 1995. Of 11,124 citations, 332 were identified for full-text review to determine inclusion. We abstracted articles for the intent of the consensus process, key elements of the methodology, and mode of information delivery. A Fisher exact test was used to identify elements that differed among the guidelines generated for clinical trials and routine care. RESULTS Overall, 142 guidelines were included, of which 16 (11%) were developed for a clinical trial. There was an increase in guideline publication over time (0 from 1995-1999 vs 65 from 2015- 2019; P = .03), particularly among recommendations for stereotactic radiation and brachytherapy. The most common disease sites were head and neck (24%), gastrointestinal (12%), and gynecologic (12%). Methods used to develop recommendations included literature review (50%) and image-based methods (45%). Panels included a median of 10 physicians (interquartile range, 7-16); 70% of panels represented multidisciplinary expertise. Guidelines developed for a clinical trial were more likely to include an image-based approach, with quantitative analysis of contours submitted by the panel members and to publish a full set of image-based recommendations (P < .005). CONCLUSIONS This review highlights an increase in consensus contouring recommendations over time. Guidelines focus on disease sites, such as head and neck, with evidence supporting a correlation between treatment planning and patient outcomes, although variation exists in the approach to the consensus process. Elements that may improve guideline acceptance (ie, image-based consensus contour analysis) and usability (ie, inclusion of a full image set) are more common in guidelines developed for clinical trials.
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Affiliation(s)
- Diana Lin
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kaitlyn Lapen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael V Sherer
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Jolie Kantor
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lindsay M Boyce
- Memorial Sloan Kettering Library, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Walter Bosch
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Deborah Korenstein
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York.
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Gering D, Kotrotsou A, Young-Moxon B, Miller N, Avery A, Kohli L, Knapp H, Hoffman J, Chylla R, Peitzman L, Mackie TR. Measuring Efficiency of Semi-automated Brain Tumor Segmentation by Simulating User Interaction. Front Comput Neurosci 2020; 14:32. [PMID: 32372938 PMCID: PMC7177174 DOI: 10.3389/fncom.2020.00032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/24/2020] [Indexed: 11/13/2022] Open
Abstract
Traditionally, radiologists have crudely quantified tumor extent by measuring the longest and shortest dimension by dragging a cursor between opposite boundary points across a single image rather than full segmentation of the volumetric extent. For algorithmic-based volumetric segmentation, the degree of radiologist experiential involvement varies from confirming a fully automated segmentation, to making a single drag on an image to initiate semi-automated segmentation, to making multiple drags and clicks on multiple images during interactive segmentation. An experiment was designed to test an algorithm that allows various levels of interaction. Given the ground-truth of the BraTS training data, which delimits the brain tumors of 285 patients on multi-spectral MR, a computer simulation mimicked the process that a radiologist would follow to perform segmentation with real-time interaction. Clicks and drags were placed only where needed in response to the deviation between real-time segmentation results and assumed radiologist's goal, as provided by the ground-truth. Results of accuracy for various levels of interaction are presented along with estimated elapsed time, in order to measure efficiency. Average total elapsed time, including loading the study through confirming 3D contours, was 46 s.
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Affiliation(s)
| | | | | | | | | | - Lisa Kohli
- HealthMyne Inc., Madison, WI, United States
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Arculeo S, Miglietta E, Nava F, Morra A, Leonardi MC, Comi S, Ciardo D, Fiore MS, Gerardi MA, Pepa M, Gugliandolo SG, Livi L, Orecchia R, Jereczek-Fossa BA, Dicuonzo S. The emerging role of radiation therapists in the contouring of organs at risk in radiotherapy: analysis of inter-observer variability with radiation oncologists for the chest and upper abdomen. Ecancermedicalscience 2020; 14:996. [PMID: 32153651 PMCID: PMC7032938 DOI: 10.3332/ecancer.2020.996] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Indexed: 12/25/2022] Open
Abstract
Aims To compare the contouring of organs at risk (OAR) between a clinical specialist radiation therapist (CSRT) and radiation oncologists (ROs) with different levels of expertise (senior–SRO, junior–JRO, fellow–FRO). Methods On ten planning computed tomography (CT) image sets of patients undergoing breast radiotherapy (RT), the observers independently contoured the contralateral breast, heart, left anterior descending artery (LAD), oesophagus, kidney, liver, spinal cord, stomach and trachea. The CSRT was instructed by the JRO e SRO. The inter-observer variability of contoured volumes was measured using the Dice similarity coefficient (DSC) (threshold of ≥ 0.7 for good concordance) and the centre of mass distance (CMD). The analysis of variance (ANOVA) was performed and a p-value < 0.01 was considered statistically significant. Results Good overlaps (DSC > 0.7) were obtained for all OARs, except for LAD (DSC = 0.34 ± 0.17, mean ± standard deviation) and oesophagus (DSC = 0.66 ± 0.06, mean ± SD). The mean CMD < 1 cm was achieved for all the OARs, but spinal cord (CMD = 1.22 cm). By pairing the observers, mean DSC > 0.7 and mean CMD < 1 cm were achieved in all cases. The best overlaps were seen for the pairs JRO-CSRT(DSC = 0.82; CMD = 0.49 cm) and SRO-JRO (DSC = 0.80; CMD = 0.51 cm). Conclusions Overall, good concordance was found for all the observers. Despite the short training in contouring, CSRT obtained good concordance with his tutor (JRO). Great variability was seen in contouring the LAD, due to its difficult visualization and identification of CT scans without contrast.
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Affiliation(s)
- Simona Arculeo
- Division of Radiation Oncology, European Institute of Oncology IRCCS (IEO), Via Ripamonti 435, 20141 Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Eleonora Miglietta
- Division of Radiation Oncology, European Institute of Oncology IRCCS (IEO), Via Ripamonti 435, 20141 Milan, Italy
| | - Fabrizio Nava
- Division of Radiation Oncology, European Institute of Oncology IRCCS (IEO), Via Ripamonti 435, 20141 Milan, Italy
| | - Anna Morra
- Division of Radiation Oncology, European Institute of Oncology IRCCS (IEO), Via Ripamonti 435, 20141 Milan, Italy
| | - Maria Cristina Leonardi
- Division of Radiation Oncology, European Institute of Oncology IRCCS (IEO), Via Ripamonti 435, 20141 Milan, Italy
| | - Stefania Comi
- Unit of Medical Physics, European Institute of Oncology IRCCS (IEO), 20141 Milan, Italy
| | - Delia Ciardo
- Division of Radiation Oncology, European Institute of Oncology IRCCS (IEO), Via Ripamonti 435, 20141 Milan, Italy
| | - Massimo Sarra Fiore
- Division of Radiation Oncology, European Institute of Oncology IRCCS (IEO), Via Ripamonti 435, 20141 Milan, Italy
| | - Marianna Alessandra Gerardi
- Division of Radiation Oncology, European Institute of Oncology IRCCS (IEO), Via Ripamonti 435, 20141 Milan, Italy
| | - Matteo Pepa
- Division of Radiation Oncology, European Institute of Oncology IRCCS (IEO), Via Ripamonti 435, 20141 Milan, Italy
| | - Simone Giovanni Gugliandolo
- Division of Radiation Oncology, European Institute of Oncology IRCCS (IEO), Via Ripamonti 435, 20141 Milan, Italy
| | - Lorenzo Livi
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Largo Piero Palagi 1, 50139 Florence, Italy
| | - Roberto Orecchia
- Scientific Directorate, European Institute of Oncology IRCCS (IEO), 20141 Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, European Institute of Oncology IRCCS (IEO), Via Ripamonti 435, 20141 Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Samantha Dicuonzo
- Division of Radiation Oncology, European Institute of Oncology IRCCS (IEO), Via Ripamonti 435, 20141 Milan, Italy
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Oultram S, Dempsey S, Greer P, Clapham M. Comparing Breast Conservation Surgery Seromas Contoured by Radiation Therapists versus those Contoured by a Radiation Oncologist in Radiation Therapy Planning for Early-Stage Breast Cancer. J Med Imaging Radiat Sci 2020; 51:108-116. [PMID: 31983574 DOI: 10.1016/j.jmir.2019.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 10/28/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION In the management of early-stage breast cancer using radiation therapy, computed tomography (CT) simulation is used to identify the breast conservation surgery (BCS) seroma as a proxy for the tumour bed. The delineation or contouring of the seroma is generally a task performed by a radiation oncologist (RO). With increasing patient numbers and other demands placed on ROs, the scope of practice for radiation therapists (RTs) is continually expanding, and the need for skills transfer from one profession to another has been investigated in recent years. This study aims to compare the BCS seroma volumes contoured by RTs with those contoured by ROs to add evidence in support of expanding the RTs' role in the treatment planning process in the management of early-stage breast cancer. METHODS A study was undertaken using the CT-simulation (CT-sim) data sets of patients with early-stage breast cancer treated in 2013. The CT-sim data sets had BCS seromas contoured by 1 of 5 ROs as part of routine clinical management. This study involved 4 RTs who each used the patient information to identify and contour breast seromas on 50 deidentified CT-sim data sets. Metrics used to compare RT versus RO contours included volume size, overlap between volumes, and geographical distance from the centre of volumes. RESULTS There were 50 CT-sim data sets with 1 RO contour and 4 RT contours analysed. The contour volumes of the 4 RTs and the ROs were assessed. Although there were 50 CT-sim data sets presented to each RT, analysis was carried out on 45, 43, 46, and 45 CT-sim data sets. There were no comparisons made where contours were not delineated. The contour volumes of the 4 RTs and the ROs were assessed with an interclass correlation coefficient, with a result of excellent reliability (0.975, 95% [0.963, 0.985]). The DICE similarity coefficient was used to compare the overlap of each RT contour with the RO contour; the results were favourable with mean (95% CI) DSCs 0.685, 0.640, 0.678, and 0.681, respectively. Comparing the RT and RO geographical centre of the seroma volumes, good to excellent reliability between the RTs and ROs was demonstrated (95% CI mean RO vs RT distances (mm): 3.75, 4.99, 7.71, and 3.39). There was no statistically significant difference between the distances (P = 0.65). CONCLUSION BCS seromas contoured by RTs compared well with those contoured by an RO. This research has provided further evidence to support RTs in assuming additional contouring responsibilities in radiation therapy planning for patients with early-stage breast cancer.
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Affiliation(s)
- Sharon Oultram
- Senior Clinical Radiation Therapy Educator, MPhil (Research) Candidate, Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia.
| | - Shane Dempsey
- Head of School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | - Peter Greer
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Matthew Clapham
- Clinical Research Design, IT, and Statistical Support (CReDITTS), Hunter Medical Research Institute, Lot 1 Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
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Almahariq MF, Maywood MJ, Levitin RB, Squires BS, Jawad MS, Chen PY, Gustafson GS, Dilworth JT. Mapping of Metastatic Level I Axillary Lymph Nodes in Patients with Newly Diagnosed Breast Cancer. Int J Radiat Oncol Biol Phys 2020; 106:811-820. [PMID: 31928847 DOI: 10.1016/j.ijrobp.2019.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/27/2019] [Accepted: 12/04/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE We examined the distribution of pretreatment nodal metastases to the level I axilla (Ax-L1) to assess the appropriateness of current breast atlases and provide guidelines in relationship to easily identifiable anatomic landmarks for accurate delineation of this lymph node (LN) basin. METHODS AND MATERIALS Patients with newly diagnosed breast cancer and biopsy-proven metastatic Ax-L1 LNs were identified. We related the location of each LN to its most adjacent rib and its distance from the bottom of the humeral head, axillary vessels, and a line connecting the anterior aspects of the pectoralis and latissimus dorsi muscles (P-L line). LNs were mapped onto a representative planning computed tomography scan, and their distribution was used to validate the current Radiation Therapy Oncology Group, European Society for Radiotherapy and Oncology, and Radiotherapy Comparative Effectiveness breast atlases. Furthermore, we examined metastases to a subregion encompassing the superolateral Ax-L1, irradiation of which correlates highly with lymphedema. RESULTS We identified 106 eligible patients with 107 biopsied LNs. All LNs fell between the second and fifth ribs (mean, 3.8 ± 0.56). Mean distance from the inferior aspect of the humeral head was 4.3 ± 1.6 cm (range, 0.3-8.4). Mean distance from the inferior aspect of the axillary vessels was 2.9 ± 1.5 cm (range, -0.6 to 5.4). Mean distance from the P-L line was 0.01 ± 1.9 cm (range, -2.2 to 2.4); negative and positive values denote medial or lateral to the P-L line. A Radiation Therapy Oncology Group-compliant Ax-L1 consensus contour, created from contours by 4 attending breast radiation oncologists, partially or fully missed 45% of mapped LNs. European Society for Radiotherapy and Oncology- and Radiotherapy Comparative Effectiveness-compliant Ax-L1 similarly missed 46% and 34% of mapped LNs, respectively. LNs were most frequently missed in the lateral direction. The superolateral Ax-L1 encompassed 9.3% of the mapped LNs. CONCLUSIONS A significant percentage of at-risk Ax-L1 tissue falls outside current contouring atlases. We propose expansion of the recommended Ax-L1 borders, most notably in the lateral direction.
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Affiliation(s)
| | - Michael J Maywood
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Ronald B Levitin
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Bryan S Squires
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Maha S Jawad
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | | | - Joshua T Dilworth
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan.
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30
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Vaassen F, Hazelaar C, Vaniqui A, Gooding M, van der Heyden B, Canters R, van Elmpt W. Evaluation of measures for assessing time-saving of automatic organ-at-risk segmentation in radiotherapy. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2019; 13:1-6. [PMID: 33458300 PMCID: PMC7807544 DOI: 10.1016/j.phro.2019.12.001] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/02/2019] [Accepted: 12/02/2019] [Indexed: 12/01/2022]
Abstract
Automatic delineation software shows promising results in terms of time-saving. Standard geometry measures do not have a high correlation with delineation time. New evaluation measures were introduced: added path length (APL) and surface DSC. (Added) path length showed the highest correlation with time-recordings. This makes APL the most representative measure for clinical usefulness.
Background and purpose In radiotherapy, automatic organ-at-risk segmentation algorithms allow faster delineation times, but clinically relevant contour evaluation remains challenging. Commonly used measures to assess automatic contours, such as volumetric Dice Similarity Coefficient (DSC) or Hausdorff distance, have shown to be good measures for geometric similarity, but do not always correlate with clinical applicability of the contours, or time needed to adjust them. This study aimed to evaluate the correlation of new and commonly used evaluation measures with time-saving during contouring. Materials and methods Twenty lung cancer patients were used to compare user-adjustments after atlas-based and deep-learning contouring with manual contouring. The absolute time needed (s) of adjusting the auto-contour compared to manual contouring was recorded, from this relative time-saving (%) was calculated. New evaluation measures (surface DSC and added path length, APL) and conventional evaluation measures (volumetric DSC and Hausdorff distance) were correlated with time-recordings and time-savings, quantified with the Pearson correlation coefficient, R. Results The highest correlation (R = 0.87) was found between APL and absolute adaption time. Lower correlations were found for APL with relative time-saving (R = −0.38), for surface DSC with absolute adaption time (R = −0.69) and relative time-saving (R = 0.57). Volumetric DSC and Hausdorff distance also showed lower correlation coefficients for absolute adaptation time (R = −0.32 and 0.64, respectively) and relative time-saving (R = 0.44 and −0.64, respectively). Conclusion Surface DSC and APL are better indicators for contour adaptation time and time-saving when using auto-segmentation and provide more clinically relevant and better quantitative measures for automatically-generated contour quality, compared to commonly-used geometry-based measures.
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Affiliation(s)
- Femke Vaassen
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Colien Hazelaar
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ana Vaniqui
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Brent van der Heyden
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Richard Canters
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
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Leung E, D'Souza D, Bachand F, Han K, Alfieri J, Huang F, Vigneault E, Barkati M, Wiebe EM, Foster W, Fortin I, Velker V, Bowes D, Barnes E, Patil N, Banerjee R, Barbera L, Ravi A. MRI-based interstitial brachytherapy for vaginal tumors: A multi-institutional study on practice patterns, contouring, and consensus definitions of target volumes. Brachytherapy 2019; 18:598-605. [PMID: 31230941 DOI: 10.1016/j.brachy.2019.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 05/10/2019] [Accepted: 05/20/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE Interstitial brachytherapy (ISBT) can be effective for vaginal tumors due to its ability to deliver conformal treatment with 3D planning. As there is no consensus for 3D vaginal brachytherapy (BT) contouring, the goals of this study are to evaluate the variability in practices and contouring, and to develop consensus concepts on target definitions. METHODS A survey/contouring study was conducted with 16 radiation oncologists from 10 Canadian academic centers. The study included three vaginal ISBT cases. Participants were provided staging, prebrachytherapy (pre-BT), and BT MRIs. Participants responded to a questionnaire and contoured on the provided images. Agreement between contours was analyzed. A meeting was held to develop consensus definitions of targets. RESULTS Median ISBT experience was 3.5 years. All 16 participants regularly contour with MRI, whereas three also plan on MRI. For the three cases, there was variation into how CTVHR and CTVIR was defined. Kappa statistics showed higher agreement with bulky tumors (mean 0.59) as compared with small residual tumors (mean 0.29). For all cases, kappa was highest in pre-BT GTVres as compared with BT GTVres (mean 0.58, 0.46). Consensus concepts to define targets were developed. CONCLUSIONS Variations exist in how ISBT targets are defined for vaginal tumors. Highest contouring variability was seen with small residual at BT. Contouring is more consistent on pre-BT MRI as compared with BT MRI suggesting a needle distortion effect. Consensus CTVHR and CTVIR definitions have been developed and further work is warranted to establish international standards.
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Affiliation(s)
- Eric Leung
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada.
| | - David D'Souza
- Department of Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Francois Bachand
- Department of Radiation Oncology, BC Cancer, Kelowna, British Columbia, Canada
| | - Kathy Han
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Joanne Alfieri
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Eric Vigneault
- Department of Radiation Oncology, CHU de Québec Université Laval, Québec, Québec, Ontario, Canada
| | - Maroie Barkati
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | - Ericka M Wiebe
- Department of Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - William Foster
- Department of Radiation Oncology, CHU de Québec Université Laval, Québec, Québec, Ontario, Canada
| | - Israel Fortin
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | - Vikram Velker
- Department of Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - David Bowes
- Department of Radiation Oncology, Nova Scotia Cancer Centre, Halifax, Nova Scotia, Canada
| | - Elizabeth Barnes
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada
| | - Nikhilesh Patil
- Department of Radiation Oncology, Nova Scotia Cancer Centre, Halifax, Nova Scotia, Canada
| | - Robyn Banerjee
- Division of Radiation Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Lisa Barbera
- Division of Radiation Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Ananth Ravi
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada
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Kruser TJ, Bosch WR, Badiyan SN, Bovi JA, Ghia AJ, Kim MM, Solanki AA, Sachdev S, Tsien C, Wang TJC, Mehta MP, McMullen KP. NRG brain tumor specialists consensus guidelines for glioblastoma contouring. J Neurooncol 2019; 143:157-166. [PMID: 30888558 DOI: 10.1007/s11060-019-03152-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 03/11/2019] [Indexed: 01/19/2023]
Abstract
INTRODUCTION NRG protocols for glioblastoma allow for clinical target volume (CTV) reductions at natural barriers; however, literature examining CTV contouring and the relevant white matter pathways is lacking. This study proposes consensus CTV guidelines, with a focus on areas of controversy while highlighting common errors in glioblastoma target delineation. METHODS Ten academic radiation oncologists specializing in brain tumor treatment contoured CTVs on four glioblastoma cases. CTV expansions were based on NRG trial guidelines. Contour consensus was assessed and summarized by kappa statistics. A meeting was held to discuss the mathematically averaged contours and form consensus contours and recommendations. RESULTS Contours of the cavity plus enhancement (mean kappa 0.69) and T2-FLAIR signal (mean kappa 0.74) showed moderate to substantial agreement. Experts were asked to trim off anatomic barriers while respecting pathways of spread to develop their CTVs. Submitted CTV_4600 (mean kappa 0.80) and CTV_6000 (mean kappa 0.81) contours showed substantial to near perfect agreement. Simultaneous truth and performance level estimation (STAPLE) contours were then reviewed and modified by group consensus. Anatomic trimming reduced the amount of total brain tissue planned for radiation targeting by a 13.6% (range 8.7-17.9%) mean proportional reduction. Areas for close scrutiny of target delineation were described, with accompanying recommendations. CONCLUSIONS Consensus contouring guidelines were established based on expert contours. Careful delineation of anatomic pathways and barriers to spread can spare radiation to uninvolved tissue without compromising target coverage. Further study is necessary to accurately define optimal target volumes beyond isometric expansion techniques for individual patients.
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Affiliation(s)
- Tim J Kruser
- Department of Radiation Oncology, Northwestern Memorial Hospital, 251 E Huron St, LC-178, Galter Pavilion, Chicago, IL, 60611, USA.
| | - Walter R Bosch
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Joseph A Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amol J Ghia
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Abhishek A Solanki
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Sean Sachdev
- Department of Radiation Oncology, Northwestern Memorial Hospital, 251 E Huron St, LC-178, Galter Pavilion, Chicago, IL, 60611, USA
| | - Christina Tsien
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University Medical Center, New York, NY, USA
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Inter-observer variability of clinical target volume delineation in definitive radiotherapy of neck lymph node metastases from unknown primary. A cooperative study of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) Head and Neck Group. Radiol Med 2019; 124:682-692. [PMID: 30852793 DOI: 10.1007/s11547-019-01006-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 02/11/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND This study, promoted by Italian Association of Radiotherapy and Clinical Oncology (AIRO) Head and Neck Group, aimed to assess the current national practice of target volume delineation on a case of neck lymph node metastases from unknown primary evaluating inter-observer variability, in a setting of primary radiotherapy. MATERIALS AND METHODS A case of metastatic neck lymph node from occult primary was proposed to 17 radiation oncologists. A national reference RT center was identified and considered as benchmark. Participants were requested to delineate target volumes. A structured questionnaire was administered. A comparison between following parameters of the CTVs was performed: centroids distances, Dice similarity index (DSI), Jaccard index and mean distance to agreement (MDA). Volume expressed in cubic centimeters and CTVs cranio-caudal extension were evaluated. RESULTS Sixteen of 17 radiation oncologists recommended three CTVs dose levels. (CTV HD, CTV ID and CTV LD); CTV ID was not delineated by one of the participants and by the reference center. The distance between the reference centroid and the mean centroid of CTVs HD was 1.09 cm (0.36-3.99 cm); for CTV LD, a mean centroids distance of 2.45 (0.27-4.83 cm) was found, and for CTV HD, mean DSI is 0.48 and mean Jaccard index is 0.32 and MDA was 8.89 mm. CTV LD showed a mean DSI of 0.46, mean Jaccard index of 0.31 and MDA of 14.87 when compared to the reference. CONCLUSION Many aspects concerning treatment optimization of cervical nodes metastases from occult primary remain unclear, and we found a notable heterogeneity of global radiotherapy management reporting discordances both in target volume delineation and volume prescription.
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Elhalawani H, Elgohari B, Lin TA, Mohamed ASR, Fitzgerald TJ, Laurie F, Ulin K, Kalpathy-Cramer J, Guerrero T, Holliday EB, Russo G, Patel A, Jones W, Walker GV, Awan M, Choi M, Dagan R, Mahmoud O, Shapiro A, Kong FMS, Gomez D, Zeng J, Decker R, Spoelstra FOB, Gaspar LE, Kachnic LA, Thomas CR, Okunieff P, Fuller CD. An in-silico quality assurance study of contouring target volumes in thoracic tumors within a cooperative group setting. Clin Transl Radiat Oncol 2019; 15:83-92. [PMID: 30775563 PMCID: PMC6365802 DOI: 10.1016/j.ctro.2019.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 12/25/2022] Open
Abstract
We aimed at quantifying inter-observer Pancoast tumors delineation variability. Experts’ delineations were used to define ground truth. Other observers’ delineations were compared against ground truth. High degree of variability was noted for most target volumes except GTV_P. This unveils potentials for protocol modification for future IMRT studies.
Introduction Target delineation variability is a significant technical impediment in multi-institutional trials which employ intensity modulated radiotherapy (IMRT), as there is a real potential for clinically meaningful variances that can impact the outcomes in clinical trials. The goal of this study is to determine the variability of target delineation among participants from different institutions as part of Southwest Oncology Group (SWOG) Radiotherapy Committee’s multi-institutional in-silico quality assurance study in patients with Pancoast tumors as a “dry run” for trial implementation. Methods CT simulation scans were acquired from four patients with Pancoast tumor. Two patients had simulation 4D-CT and FDG-FDG PET-CT while two patients had 3D-CT and FDG-FDG PET-CT. Seventeen SWOG-affiliated physicians independently delineated target volumes defined as gross primary and nodal tumor volumes (GTV_P & GTV_N), clinical target volume (CTV), and planning target volume (PTV). Six board-certified thoracic radiation oncologists were designated as the ‘Experts’ for this study. Their delineations were used to create a simultaneous truth and performance level estimation (STAPLE) contours using ADMIRE software (Elekta AB, Sweden 2017). Individual participants’ contours were then compared with Experts’ STAPLE contours. Results When compared to the Experts’ STAPLE, GTV_P had the best agreement among all participants, while GTV_N showed the lowest agreement among all participants. There were no statistically significant differences in all studied parameters for all TVs for cases with 4D-CT versus cases with 3D-CT simulation scans. Conclusions High degree of inter-observer variation was noted for all target volume except for GTV_P, unveiling potentials for protocol modification for subsequent clinically meaningful improvement in target definition. Various similarity indices exist that can be used to guide multi-institutional radiotherapy delineation QA credentialing.
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Affiliation(s)
- Hesham Elhalawani
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA
| | - Baher Elgohari
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA
| | - Timothy A Lin
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA.,Baylor College of Medicine, TX 77030, USA
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA.,Department of Clinical Oncology and Nuclear Medicine, Alexandria University, Alexandria, Egypt
| | - Thomas J Fitzgerald
- Imaging and Radiation Oncology Core QA Center Rhode Island, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Fran Laurie
- Imaging and Radiation Oncology Core QA Center Rhode Island, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kenneth Ulin
- Imaging and Radiation Oncology Core QA Center Rhode Island, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Massachusetts, USA
| | - Thomas Guerrero
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Emma B Holliday
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA
| | - Gregory Russo
- Department of Radiation Oncology, Boston Medical Center, Massachusetts, USA
| | - Abhilasha Patel
- Department of Radiation Oncology, University of Texas Health Sciences Center at San Antonio, TX, USA
| | - William Jones
- Department of Radiation Oncology, University of Texas Health Sciences Center at San Antonio, TX, USA
| | - Gary V Walker
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA.,Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona, USA
| | - Musaddiq Awan
- Department of Radiation Oncology, Case Western Reserve University, OH, USA
| | - Mehee Choi
- Department of Radiation Oncology, Northwestern University, IL, USA
| | - Roi Dagan
- University of Florida Health Proton Therapy Institute, FL, USA
| | - Omar Mahmoud
- Department of Radiation Oncology, University of Miami, FL, USA
| | - Anna Shapiro
- Department of Radiation Oncology, Upstate Cancer Center, SUNY Upstate Medical University, NY, USA
| | - Feng-Ming Spring Kong
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, OH, USA
| | - Daniel Gomez
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA
| | - Jing Zeng
- Department of Radiation Oncology, University of Washington Medical Center, WA, USA
| | - Roy Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, Connecticut, USA
| | - Femke O B Spoelstra
- Department of Radiation Oncology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Laurie E Gaspar
- Department of Radiation Oncology, Vanderbilt University, TN, USA
| | - Lisa A Kachnic
- Department of Radiation Oncology, Vanderbilt University Medical Center, Tennessee, USA
| | - Charles R Thomas
- Department of Radiation Medicine, Oregon Health & Science University, Oregon, USA
| | - Paul Okunieff
- SWOG, Department of Radiation Oncology, University of Florida College of Medicine, Florida, USA
| | - Clifton D Fuller
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, TX 77030, USA
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Clinical evaluation of an MRI-to-ultrasound deformable image registration algorithm for prostate brachytherapy. Brachytherapy 2019; 18:95-102. [DOI: 10.1016/j.brachy.2018.08.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/16/2018] [Accepted: 08/08/2018] [Indexed: 11/21/2022]
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Andrianarison VA, Laouiti M, Fargier-Bochaton O, Dipasquale G, Wang X, Nguyen NP, Miralbell R, Vinh-Hung V. Contouring workload in adjuvant breast cancer radiotherapy. Cancer Radiother 2018; 22:747-753. [PMID: 30322819 DOI: 10.1016/j.canrad.2018.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE To measure the impact of contouring on worktime in the adjuvant radiation treatment of breast cancer, and to identify factors that might affect the measurements. MATERIAL AND METHODS The dates and times of contouring clinical target volumes and organs at risk were recorded by a senior and by two junior radiation oncologists. Outcome measurements were contour times and the time from start to approval. The factors evaluated were patient age, type of surgery, radiation targets and setup, operator, planning station, part of the day and day of the week on which the contouring started. The Welch test was used to comparatively assess the measurements. RESULTS Two hundred and three cases were included in the analysis. The mean contour time per patient was 34minutes for a mean of 4.72 structures, with a mean of 7.1minutes per structure. The clinical target volume and organs at risk times did not differ significantly. The mean time from start to approval per patient was 29.4hours. Factors significantly associated with longer contour times were breast-conserving surgery (P=0.026), prone setup (P=0.002), junior operator (P<0.0001), Pinnacle planning station (P=0.026), contouring start in the morning (P=0.001), and contouring start by the end of the week (P<0.0001). Factors significantly associated with time from start to approval were age (P=0.038), junior operator (P<0.0001), planning station (P=0.016), and contouring start by the end of the week (P=0.004). CONCLUSION Contouring is a time-consuming process. Each delineated structure influences worktime, and many factors may be targeted for optimization of the workflow. These preliminary data will serve as basis for future prospective studies to determine how to establish a cost-effective solution.
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Affiliation(s)
- V A Andrianarison
- Radiation Oncology, CHU de Martinique, boulevard Pasteur, 97200 Fort-de-France, Martinique; Joseph-Ravoahangy-Andrianavalona University Hospital, Antananarivo 101, Madagascar
| | - M Laouiti
- Radiation Oncology, hôpital Fribourgeois, 1708 Fribourg, Switzerland
| | - O Fargier-Bochaton
- Radiation Oncology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - G Dipasquale
- Radiation Oncology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - X Wang
- Radiation Oncology, Tianjin Union Medical Center, Tianjin 300121, China
| | - N P Nguyen
- Radiation Oncology, Howard University Hospital, Washington DC 20060, United States
| | - R Miralbell
- Radiation Oncology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - V Vinh-Hung
- Radiation Oncology, CHU de Martinique, boulevard Pasteur, 97200 Fort-de-France, Martinique.
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Ng SP, Dyer BA, Kalpathy-Cramer J, Mohamed ASR, Awan MJ, Gunn GB, Phan J, Zafereo M, Debnam JM, Lewis CM, Colen RR, Kupferman ME, Guha-Thakurta N, Canahuate G, Marai GE, Vock D, Hamilton B, Holland J, Cardenas CE, Lai S, Rosenthal D, Fuller CD. A prospective in silico analysis of interdisciplinary and interobserver spatial variability in post-operative target delineation of high-risk oral cavity cancers: Does physician specialty matter? Clin Transl Radiat Oncol 2018; 12:40-46. [PMID: 30148217 PMCID: PMC6105928 DOI: 10.1016/j.ctro.2018.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 07/31/2018] [Indexed: 11/21/2022] Open
Abstract
Background The aim of this study was to determine the interdisciplinary agreement in identifying the post-operative tumor bed. Methods Three radiation oncologists (ROs), four surgeons, and three radiologists segmented post-operative tumor and nodal beds for three patients with oral cavity cancer. Specialty cohort composite contours were created by STAPLE algorithm implementation results for interspecialty comparison. Dice similarity coefficient and Hausdorff distance were utilized to compare spatial differentials between specialties. Results There were significant differences between disciplines in target delineation. There was unacceptable variation in Dice similarity coefficient for each observer and discipline when compared to the STAPLE contours. Within surgery and radiology disciplines, there was good consistency in volumes. ROs and radiologists have similar Dice similarity coefficient scores compared to surgeons. Conclusion There were significant interdisciplinary differences in perceptions of tissue-at-risk. Better communication and explicit description of at-risk areas between disciplines is required to ensure high-risk areas are adequately targeted.
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Affiliation(s)
- Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brandon A Dyer
- Department of Radiation Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California, USA
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | | | - Musaddiq J Awan
- Department of Radiation Oncology, Case Western Reserve University, Cleveland, Ohio, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark Zafereo
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - J Matthew Debnam
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carol M Lewis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rivka R Colen
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael E Kupferman
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nandita Guha-Thakurta
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guadalupe Canahuate
- Department of Electrical & Computer Engineering, University of Iowa, Iowa City, Iowa, USA
| | - G Elisabeta Marai
- Department of Computer Science, University of Illinois at Chicago, Chicago, Illinois, USA
| | - David Vock
- Department of Biostatistics, University of Minnesota of Public Health, Minneapolis, Minnesota, USA
| | - Bronwyn Hamilton
- Department of Radiology, Oregon Health & Science University, Portland, Oregon, USA
| | - John Holland
- Department of Radiation Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Carlos E Cardenas
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Clifton David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Besson FL, Henry T, Meyer C, Chevance V, Roblot V, Blanchet E, Arnould V, Grimon G, Chekroun M, Mabille L, Parent F, Seferian A, Bulifon S, Montani D, Humbert M, Chaumet-Riffaud P, Lebon V, Durand E. Rapid Contour-based Segmentation for 18F-FDG PET Imaging of Lung Tumors by Using ITK-SNAP: Comparison to Expert-based Segmentation. Radiology 2018; 288:277-284. [DOI: 10.1148/radiol.2018171756] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Delouya G, Carrier JF, Xavier-Larouche R, Hervieux Y, Béliveau-Nadeau D, Donath D, Taussky D. Fusion of Intraoperative Transrectal Ultrasound Images with Post-implant Computed Tomography and Magnetic Resonance Imaging. Cureus 2018; 10:e2394. [PMID: 29850389 PMCID: PMC5973483 DOI: 10.7759/cureus.2394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Purpose To compare the impact of the fusion of intraoperative transrectal ultrasound (TRUS) images with day 30 computed tomography (CT) and magnetic resonance imaging (MRI) on prostate volume and dosimetry. Methods and materials Seventy-five consecutive patients with CT and MRI obtained on day 30 with a Fast Spin Echo T2-weighted magnetic resonance (MR) sequence were analyzed. A rigid manual registration was performed between the intraoperative TRUS and day-30 CT based on the prostate volume. A second manual rigid registration was performed between the intraoperative TRUS and the day-30 MRI. The prostate contours were manually modified on CT and MRI. The difference in prostate volume and dosimetry between CT and MRI were compared. Results Prostate volume was on average 8% (standard deviation (SD) ± 16%) larger on intraoperative TRUS than on CT and 6% (18%) larger than on MRI. In 48% of the cases, the difference in volume on CT was > 10% compared to MRI. The difference in prostate volume between CT and MRI was inversely correlated to the difference in D90 (minimum dose that covers 90% of the prostate volume) between CT and MRI (r = -0.58, P < .001). A D90 < 90% was found in 5% (n = 4) on MRI and in 10% (n = 7) on CT (Fisher exact test one-sided P = .59), but in no patient was the D90 < 90% on both MRI and CT. Conclusions When fusing TRUS images with CT and MRI, the differences in prostate volume between those modalities remain clinically important in nearly half of the patients, and this has a direct influence on how implant quality is evaluated.
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Affiliation(s)
- Guila Delouya
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal (CHUM)
| | - Jean-Francois Carrier
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal (CHUM)
| | - Renée Xavier-Larouche
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal (CHUM)
| | - Yannick Hervieux
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal (CHUM)
| | | | - David Donath
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal (CHUM)
| | - Daniel Taussky
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal (CHUM)
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The TRENDY multi-center randomized trial on hepatocellular carcinoma – Trial QA including automated treatment planning and benchmark-case results. Radiother Oncol 2017; 125:507-513. [DOI: 10.1016/j.radonc.2017.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/07/2017] [Accepted: 09/09/2017] [Indexed: 11/20/2022]
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Soliman H, Ruschin M, Angelov L, Brown PD, Chiang VLS, Kirkpatrick JP, Lo SS, Mahajan A, Oh KS, Sheehan JP, Soltys SG, Sahgal A. Consensus Contouring Guidelines for Postoperative Completely Resected Cavity Stereotactic Radiosurgery for Brain Metastases. Int J Radiat Oncol Biol Phys 2017; 100:436-442. [PMID: 29157748 DOI: 10.1016/j.ijrobp.2017.09.047] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/08/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To propose contouring guidelines based on consensus contours generated by 10 international experts for cavity stereotactic radiosurgery (SRS), an emerging treatment option after surgical resection of brain metastases. No guidelines for contouring the surgical cavity volume have been previously reported. METHODS AND MATERIALS Ten postoperative completely resected cases with varying clinical scenarios and locations within the brain were selected. For each case, 10 experts independently contoured the surgical cavity clinical target volume (CTV). All the contours were analyzed, and agreement was calculated using the simultaneous truth and performance level estimation (STAPLE) with the kappa statistic. A follow-up survey was also completed by each investigator to summarize their contouring rationale for a number of different clinical scenarios. The results from the survey and the consensus STAPLE contours were both summarized to establish contouring guidelines. RESULTS A high level of agreement was found between the expert CTV contours (mean sensitivity 0.75, mean specificity 0.98), and the mean kappa was 0.65. The agreement was statistically significant at P<.001 for all cases. From these results and analyses of the survey answers, the recommendations for CTV include fusion of the preoperative magnetic resonance imaging scan to aid in volume delineation; contouring the entire surgical tract regardless of the preoperative location of the tumor; extension of the CTV 5 to 10 mm along the dura overlying the bone flap to account for microscopic disease extension in cases with preoperative dural contact; and a margin of ≤5 mm into the adjacent sinus when preoperative venous sinus contact was present. CONCLUSIONS Consensus contouring guidelines for postoperative completely resected cavity SRS treatment were established using expert contours and clinical practice. However, in the absence of clinical data supporting these recommendations, these guidelines serve as a baseline for further study and refinement.
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Affiliation(s)
- Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Center, University of Toronto, Toronto, Ontario, Canada.
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Odette Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Lilyana Angelov
- Department of Neurological Surgery, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Veronica L S Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - John P Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Kevin S Oh
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University, Stanford, California
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Center, University of Toronto, Toronto, Ontario, Canada
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Chen GP, Noid G, Tai A, Liu F, Lawton C, Erickson B, Li XA. Improving CT quality with optimized image parameters for radiation treatment planning and delivery guidance. Phys Imaging Radiat Oncol 2017. [DOI: 10.1016/j.phro.2017.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Kristensen I, Nilsson K, Agrup M, Belfrage K, Embring A, Haugen H, Svärd AM, Knöös T, Nilsson P. A dose based approach for evaluation of inter-observer variations in target delineation. Tech Innov Patient Support Radiat Oncol 2017; 3-4:41-47. [PMID: 32095566 PMCID: PMC7033785 DOI: 10.1016/j.tipsro.2017.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 10/06/2017] [Accepted: 10/09/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Substantial inter-observer variations in target delineation have been presented previously. Target delineation for paediatric cases is difficult due to the small number of children, the variation in paediatric targets, the number of study protocols, and the individual patient's specific needs and demands. Uncertainties in target delineation might lead to under-dosage or over-dosage. The aim of this work is to apply the concept of a consensus volume and good quality treatment plans to visualise and quantify inter-observer target delineation variations in dosimetric terms in addition to conventional geometrically based volume concordance indices. MATERIAL AND METHODS Two paediatric cases were used to demonstrate the potential of adding dose metrics when evaluating target delineation diversity; Hodgkin's disease (case 1) and rhabdomyosarcoma of the parotid gland (case 2). The variability in target delineation (PTV delineations) between six centres was quantified using the generalised conformity index, CIgen, generated for volume overlap. The STAPLE algorithm, as implemented in CERR, was used for both cases to derive a consensus volumes. STAPLE is a probabilistic estimate of the true volume generated from all observers. Dose distributions created by each centre for the original target volumes were then applied to this consensus volume. RESULTS A considerable variation in target segmentation was seen in both cases. For case 1 the variation was 374-960 cm3 (average 669 cm3) and for case 2; 65-126 cm3 (average 109 cm3). CIgen were 0.53 and 0.70, respectively. The DVHs in absolute volume displayed for the delineated target volume as well as for the consensus volume adds information on both "compliant" target volumes as well as outliers which are hidden with just the use of concordance indices. CONCLUSIONS The DVHs in absolute volume add valuable and easily understood information to various indices for evaluating uniformity in target delineation.
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Affiliation(s)
- Ingrid Kristensen
- Department of Oncology, Clinical Sciences, Lund University, Lund, Sweden
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Kristina Nilsson
- Department of Immunology, Genetics and Pathology, Experimental and Clinical Oncology, Clinical Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Måns Agrup
- Department of Oncology, Linköping University Hospital, Linköping, Sweden
| | - Karin Belfrage
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Anna Embring
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Hedda Haugen
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna-Maja Svärd
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Tommy Knöös
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
- Department of Medical Radiation Physics, Clinical Sciences, Lund University, Lund, Sweden
| | - Per Nilsson
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
- Department of Medical Radiation Physics, Clinical Sciences, Lund University, Lund, Sweden
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Ciardo D, Argenone A, Boboc GI, Cucciarelli F, De Rose F, De Santis MC, Huscher A, Ippolito E, La Porta MR, Marino L, Meaglia I, Palumbo I, Rossi F, Alpi P, Bignardi M, Bonanni A, Cante D, Ceschia T, Fabbietti L, Lupattelli M, Mantero ED, Monaco A, Porcu P, Ravo V, Silipigni S, Tozzi A, Umina V, Zerini D, Bordonaro L, Capezzali G, Clerici E, Colangione SP, Dispinzieri M, Dognini J, Donadoni L, Falivene S, Fozza A, Grilli B, Guarnaccia R, Iannacone E, Lancellotta V, Prisco A, Ricotti R, Orecchia R, Jereczek-Fossa BA, Leonardi MC. Variability in axillary lymph node delineation for breast cancer radiotherapy in presence of guidelines on a multi-institutional platform. Acta Oncol 2017; 56:1081-1088. [PMID: 28534430 DOI: 10.1080/0284186x.2017.1325004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIM To quantify the variability between radiation oncologists (ROs) when outlining axillary nodes in breast cancer. MATERIAL AND METHODS For each participating center, three ROs with different levels of expertise, i.e., junior (J), senior (S) and expert (E), contoured axillary nodal levels (L1, L2, L3 and L4) on the CT images of three different patients (P) of an increasing degree of anatomical complexity (from P1 to P2 to P3), according to contouring guidelines. Consensus contours were generated using the simultaneous truth and performance level estimation (STAPLE) method. RESULTS Fifteen centers and 42 ROs participated. Overall, the median Dice similarity coefficient was 0.66. Statistically significant differences were observed according to the level of expertise (better agreement for J and E, worse for S); the axillary level (better agreement for L1 and L4, worse for L3); the patient (better agreement for P1, worse for P3). Statistically significant differences in contouring were found in 18% of the inter-center comparison. Less than a half of the centers could claim to have a good agreement between the internal ROs. CONCLUSIONS The overall intra-institute and inter-institute agreement was moderate. Central lymph-node levels were the most critical and variability increased as the complexity of the patient's anatomy increased. These findings might have an effect on the interpretation of results from multicenter and even mono-institute studies.
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Affiliation(s)
- Delia Ciardo
- Division of Radiation Oncology, Istituto Europeo di Oncologia, Milano, Italy
| | - Angela Argenone
- Division of Radiotherapy, Istituto Nazionale per lo Studio e la Cura dei Tumori, Fondazione G. Pascale IRCCS, Napoli, Italy
| | | | - Francesca Cucciarelli
- Department of Internal Medicine, Radiotherapy Institute, Ospedali Riuniti Umberto I, G.M. Lancisi, G. Salesi, Ancona, Italy
| | - Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Centre and Research Hospital, Milano, Italy
| | | | | | - Edy Ippolito
- Department of Radiotherapy, Campus Bio-Medico University, Roma, Italy
| | - Maria Rosa La Porta
- Radiotherapy Department, Ivrea Community Hospital, Ivrea, Italy; Radiation Oncology Department, Tomotherapy Unit, Ospedale Regionale ‘U. Parini’, AUSL Valle d'Aosta, Aosta, Italy
| | - Lorenza Marino
- REM Radioterapia, Istituto Oncologico del Mediterraneo (IOM), Catania, Italy
| | - Ilaria Meaglia
- Department of Radiation Oncology, Fondazione Salvatore Maugeri, Pavia, Italy
| | - Isabella Palumbo
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | | | - Paolo Alpi
- Radiotherapy Unit, Azienda Sanitaria 10, Firenze, Italy
| | - Mario Bignardi
- Radiotherapy Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Alessio Bonanni
- Radiotherapy Unit, Ospedale Fatebenefratelli Isola Tiberina, Roma, Italy
| | - Domenico Cante
- Radiotherapy Department, Ivrea Community Hospital, Ivrea, Italy; Radiation Oncology Department, Tomotherapy Unit, Ospedale Regionale ‘U. Parini’, AUSL Valle d'Aosta, Aosta, Italy
| | - Tino Ceschia
- Department of Radiotherapy, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
| | - Letizia Fabbietti
- Department of Internal Medicine, Radiotherapy Institute, Ospedali Riuniti Umberto I, G.M. Lancisi, G. Salesi, Ancona, Italy
| | - Marco Lupattelli
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | | | - Alessia Monaco
- Department of Radiation Oncology, S. Camillo-Forlanini Hospital, Roma, Italy
| | - Patrizia Porcu
- Department of Radiation Oncology, Fondazione Salvatore Maugeri, Pavia, Italy
| | - Vincenzo Ravo
- Division of Radiotherapy, Istituto Nazionale per lo Studio e la Cura dei Tumori, Fondazione G. Pascale IRCCS, Napoli, Italy
| | - Sonia Silipigni
- Department of Radiotherapy, Campus Bio-Medico University, Roma, Italy
| | - Angelo Tozzi
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Centre and Research Hospital, Milano, Italy
| | - Vincenza Umina
- REM Radioterapia, Istituto Oncologico del Mediterraneo (IOM), Catania, Italy
| | - Dario Zerini
- Division of Radiation Oncology, Istituto Europeo di Oncologia, Milano, Italy
| | - Luigi Bordonaro
- REM Radioterapia, Istituto Oncologico del Mediterraneo (IOM), Catania, Italy
| | - Giorgia Capezzali
- Department of Internal Medicine, Radiotherapy Institute, Ospedali Riuniti Umberto I, G.M. Lancisi, G. Salesi, Ancona, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Centre and Research Hospital, Milano, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milano, Italy
| | | | - Michela Dispinzieri
- Radiotherapy Unit 1, National Cancer Institute of Milan, Milano, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milano, Italy
| | - Jessica Dognini
- Department of Radiation Oncology, S. Camillo-Forlanini Hospital, Roma, Italy
| | - Laura Donadoni
- Radiotherapy Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Sara Falivene
- Division of Radiotherapy, Istituto Nazionale per lo Studio e la Cura dei Tumori, Fondazione G. Pascale IRCCS, Napoli, Italy
| | - Alessandra Fozza
- Radiotherapy Department, Ivrea Community Hospital, Ivrea, Italy; Radiation Oncology Department, Tomotherapy Unit, Ospedale Regionale ‘U. Parini’, AUSL Valle d'Aosta, Aosta, Italy
| | | | - Roberta Guarnaccia
- Radiotherapy Unit, Ospedale Fatebenefratelli Isola Tiberina, Roma, Italy
| | - Eva Iannacone
- Department of Radiotherapy, Campus Bio-Medico University, Roma, Italy
| | - Valentina Lancellotta
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Agnese Prisco
- Department of Radiotherapy, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
| | - Rosalinda Ricotti
- Division of Radiation Oncology, Istituto Europeo di Oncologia, Milano, Italy
| | - Roberto Orecchia
- Scientific Directorate, European Institute of Oncology, Milano, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milano, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, Istituto Europeo di Oncologia, Milano, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milano, Italy
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Berthon B, Spezi E, Galavis P, Shepherd T, Apte A, Hatt M, Fayad H, De Bernardi E, Soffientini CD, Ross Schmidtlein C, El Naqa I, Jeraj R, Lu W, Das S, Zaidi H, Mawlawi OR, Visvikis D, Lee JA, Kirov AS. Toward a standard for the evaluation of PET-Auto-Segmentation methods following the recommendations of AAPM task group No. 211: Requirements and implementation. Med Phys 2017; 44:4098-4111. [PMID: 28474819 PMCID: PMC5575543 DOI: 10.1002/mp.12312] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 04/07/2017] [Accepted: 04/15/2017] [Indexed: 01/04/2023] Open
Abstract
Purpose The aim of this paper is to define the requirements and describe the design and implementation of a standard benchmark tool for evaluation and validation of PET‐auto‐segmentation (PET‐AS) algorithms. This work follows the recommendations of Task Group 211 (TG211) appointed by the American Association of Physicists in Medicine (AAPM). Methods The recommendations published in the AAPM TG211 report were used to derive a set of required features and to guide the design and structure of a benchmarking software tool. These items included the selection of appropriate representative data and reference contours obtained from established approaches and the description of available metrics. The benchmark was designed in a way that it could be extendable by inclusion of bespoke segmentation methods, while maintaining its main purpose of being a standard testing platform for newly developed PET‐AS methods. An example of implementation of the proposed framework, named PETASset, was built. In this work, a selection of PET‐AS methods representing common approaches to PET image segmentation was evaluated within PETASset for the purpose of testing and demonstrating the capabilities of the software as a benchmark platform. Results A selection of clinical, physical, and simulated phantom data, including “best estimates” reference contours from macroscopic specimens, simulation template, and CT scans was built into the PETASset application database. Specific metrics such as Dice Similarity Coefficient (DSC), Positive Predictive Value (PPV), and Sensitivity (S), were included to allow the user to compare the results of any given PET‐AS algorithm to the reference contours. In addition, a tool to generate structured reports on the evaluation of the performance of PET‐AS algorithms against the reference contours was built. The variation of the metric agreement values with the reference contours across the PET‐AS methods evaluated for demonstration were between 0.51 and 0.83, 0.44 and 0.86, and 0.61 and 1.00 for DSC, PPV, and the S metric, respectively. Examples of agreement limits were provided to show how the software could be used to evaluate a new algorithm against the existing state‐of‐the art. Conclusions PETASset provides a platform that allows standardizing the evaluation and comparison of different PET‐AS methods on a wide range of PET datasets. The developed platform will be available to users willing to evaluate their PET‐AS methods and contribute with more evaluation datasets.
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Affiliation(s)
- Beatrice Berthon
- Institut Langevin, ESPCI Paris, PSL Research University, CNRS UMR 7587, INSERM U979, Paris, 75012, France
| | - Emiliano Spezi
- School of Engineering, Cardiff University, Cardiff, CF24 3AA, United Kingdom
| | - Paulina Galavis
- Department of Radiation Oncology, Langone Medical Center, New York University, New York, NY, 10016, USA
| | - Tony Shepherd
- Turku PET Centre, Turku University Hospital, Turku, 20521, Finland
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Mathieu Hatt
- INSERM, UMR 1101, LaTIM, IBSAM, UBO, UBL, Brest, 29609, France
| | - Hadi Fayad
- INSERM, UMR 1101, LaTIM, IBSAM, UBO, UBL, Brest, 29609, France
| | | | - Chiara D Soffientini
- Department of Electronics Information and Bioengineering, Politecnico di Milano, Milano, 20133, Italy
| | - C Ross Schmidtlein
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Issam El Naqa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, 48103, USA
| | - Robert Jeraj
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, 53705, USA
| | - Wei Lu
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Shiva Das
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Habib Zaidi
- Division of Nuclear Medicine & Molecular Imaging, Geneva University Hospital, Geneva CH-1211, Switzerland
| | - Osama R Mawlawi
- Department of Imaging Physics, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | | | - John A Lee
- IREC/MIRO, Université catholique de Louvain (IREC/MIRO) & FNRS, Brussels, 1200, Belgium
| | - Assen S Kirov
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
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Bridge P, Fielding A, Rowntree P, Pullar A. Qualitative Evaluation of a Novel 3D Volumetric Radiotherapy Segmentation Tool. J Med Imaging Radiat Sci 2017; 48:178-183. [DOI: 10.1016/j.jmir.2016.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/27/2016] [Accepted: 10/28/2016] [Indexed: 11/27/2022]
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Aznar MC, Girinsky T, Berthelsen AK, Aleman B, Beijert M, Hutchings M, Lievens Y, Meijnders P, Meidahl Petersen P, Schut D, Maraldo MV, van der Maazen R, Specht L. Interobserver delineation uncertainty in involved-node radiation therapy (INRT) for early-stage Hodgkin lymphoma: on behalf of the Radiotherapy Committee of the EORTC lymphoma group. Acta Oncol 2017; 56:608-613. [PMID: 28105886 DOI: 10.1080/0284186x.2017.1279750] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE In early-stage classical Hodgkin lymphoma (HL) the target volume nowadays consists of the volume of the originally involved nodes. Delineation of this volume on a post-chemotherapy CT-scan is challenging. We report on the interobserver variability in target volume definition and its impact on resulting treatment plans. MATERIALS AND METHODS Two representative cases were selected (1: male, stage IB, localization: left axilla; 2: female, stage IIB, localizations: mediastinum and bilateral neck). Eight experienced observers individually defined the clinical target volume (CTV) using involved-node radiotherapy (INRT) as defined by the EORTC-GELA guidelines for the H10 trial. A consensus contour was generated and the standard deviation computed. We investigated the overlap between observer and consensus contour [Sørensen-Dice coefficient (DSC)] and the magnitude of gross deviations between the surfaces of the observer and consensus contour (Hausdorff distance). 3D-conformal (3D-CRT) and intensity-modulated radiotherapy (IMRT) plans were calculated for each contour in order to investigate the impact of interobserver variability on each treatment modality. Similar target coverage was enforced for all plans. RESULTS The median CTV was 120 cm3 (IQR: 95-173 cm3) for Case 1, and 255 cm3 (IQR: 183-293 cm3) for Case 2. DSC values were generally high (>0.7), and Hausdorff distances were about 30 mm. The SDs between all observer contours, providing an estimate of the systematic error associated with delineation uncertainty, ranged from 1.9 to 3.8 mm (median: 3.2 mm). Variations in mean dose resulting from different observer contours were small and were not higher in IMRT plans than in 3D-CRT plans. CONCLUSIONS We observed considerable differences in target volume delineation, but the systematic delineation uncertainty of around 3 mm is comparable to that reported in other tumour sites. This report is a first step towards calculating an evidence-based planning target volume margin for INRT in HL.
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Affiliation(s)
- Marianne C. Aznar
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Theodore Girinsky
- Service de Radiothérapie Oncologique, Institut Gustave Roussy, Villejuif, France
| | - Anne Kiil Berthelsen
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Berthe Aleman
- Department of Radiotherapy, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Max Beijert
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin Hutchings
- Department of Haematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Paul Meijnders
- Department of Radiation Oncology GZA, Iridium Cancer Network, University of Antwerp, Antwerp, Belgium
| | - Peter Meidahl Petersen
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Haematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Deborah Schut
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Maja V. Maraldo
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Richard van der Maazen
- Department of Radiotherapy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lena Specht
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Haematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Onal C, Cengiz M, Guler OC, Dolek Y, Ozkok S. The role of delineation education programs for improving interobserver variability in target volume delineation in gastric cancer. Br J Radiol 2017; 90:20160826. [PMID: 28339289 DOI: 10.1259/bjr.20160826] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To assess whether delineation courses for radiation oncologists improve interobserver variability in target volume delineation for post-operative gastric cancer radiotherapy planning. METHODS 29 radiation oncologists delineated target volumes in a gastric cancer patient. An experienced radiation oncologist lectured about delineation based on contouring atlas and delineation recommendations. After the course, the radiation oncologists, blinded to the previous delineation, provided delineation for the same patient. RESULTS The difference between delineated volumes and reference volumes for pre- and post-course clinical target volume (CTV) were 19.8% (-42.4 to 70.6%) and 12.3% (-12.0 to 27.3%) (p = 0.26), respectively. The planning target volume (PTV) differences pre- and post-course according to the reference volume were 20.5% (-40.7 to 93.7%) and 13.1% (-10.6 to 29.5%) (p = 0.30), respectively. The concordance volumes between the pre- and post-course CTVs and PTVs were 467.1 ± 89.2 vs 597.7 ± 54.6 cm3 (p < 0.001) and 738.6 ± 135.1 vs 893.2 ± 144.6 cm3 (p < 0.001), respectively. Minimum and maximum observer variations were seen at the cranial part and splenic hilus and at the caudal part of the CTV. The kappa indices compared with the reference contouring at pre- and post-course delineations were 0.68 and 0.82, respectively. CONCLUSION The delineation course improved interobserver variability for gastric cancer. However, impact of target volume changes on toxicity and local control should be evaluated for further studies. Advances in knowledge: This study demonstrated that a delineation course based on current recommendations helped physicians delineate smaller and more homogeneous target volumes. Better target volume delineation allows proper target volume irradiation and preventing unnecessary normal tissue irradiation.
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Affiliation(s)
- Cem Onal
- 1 Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Mustafa Cengiz
- 2 Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ozan C Guler
- 1 Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Yemliha Dolek
- 1 Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Serdar Ozkok
- 3 Department of Radiation Oncology, Faculty of Medicine, Ege University, Izmir, Turkey
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Variability in target delineation of cervical carcinoma: A Korean radiation oncology group study (KROG 15-06). PLoS One 2017; 12:e0173476. [PMID: 28301492 PMCID: PMC5354274 DOI: 10.1371/journal.pone.0173476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 02/21/2017] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine inter-observer variability in target volume definition of cervical cancer in radical and adjuvant radiotherapy (RT) settings. METHODS Eight physicians contoured CTVs of 2 patients underwent definitive and postoperative RT. Each volume was analyzed using the individual/median volume ratio and generalized conformity index (CIgen). And center of mass (COM) of each contour was calculated. Expert agreement was quantified using an expectation maximization algorithm for Simultaneous Truth and Performance Level Estimation (STAPLE). RESULTS For definitive RT, the individual/median volume ratio ranged from 0.51 to 1.41, and CIgen was 0.531. Mean 3-dimensional distances of average to each COM were 7.8 mm. For postoperative RT setting, corresponding values were 0.65-1.38, 0.563, and 5.3 mm. Kappa value of expert agreement was 0.65 and 0.67, respectively. STAPLE estimates of the sensitivity, specificity, and kappa measures of inter-physician agreement were 0.73, 0.98, and 0.65 for the definitive and 0.75, 0.98, and 0.67 for the adjuvant radiotherapy setting. The largest difference was observed in the superior-inferior direction, particularly in the upper vagina and the common iliac area. CONCLUSION As there was still some variability in target delineation, more detailed guidelines for target volume delineation and continuing education would help to reduce this uncertainty.
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An evaluation of the robustness of organ-at-risk recommendations made by GEC/ESTRO according to interobserver variability: a single-center experience. J Contemp Brachytherapy 2016; 8:349-55. [PMID: 27648090 PMCID: PMC5018524 DOI: 10.5114/jcb.2016.61738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/20/2016] [Indexed: 12/25/2022] Open
Abstract
Purpose Groupe Européen de Curiethérapie (GEC) and European Society for Radiotherapy & Oncology (ESTRO) has proposed a rectal dose constraint of the most exposed 2-cc volume (D2cc of ≤ 75 Gy EQD2α/β = 3) during external-beam plus high-dose-rate brachytherapy (HDR-BT) in localized prostate cancer patients. This study aimed to evaluate D2cc for rectal contouring via interobserver variability. Material and methods Four blinded observers contoured rectums of 5 patients. Rectal contouring anatomical limits were determined through previous consensus. Dose-volume histogram (DVH) dosimetric parameters (D0.1cc, D1cc, and D2cc) were analyzed according to GEC/ESTRO recommendations and subjected to intra- and interobserver comparisons. Latter comparisons involved coefficients of variation. For each parameter, the mean, standard deviation (SD), and range were evaluated. The effect of interobserver variation on total dose was analyzed by estimating the biologically equivalent rectal dose (EQD2α/β = 3). Results Interobserver coefficients of variation for D0.1cc, D1cc, and D2cc were 5.7%, 4.5%, and 4%, respectively. The highest interobserver rectal delineation variation yielded a rectal dose difference up to 5.8 Gy EQD2. Estimated intraobserver variation for the reported D2cc was 5.5% in the worst-case scenario (non-significant). Conclusions We observed acceptable interobserver variability in EQD2 for D2cc, with strong impacts on clinical threshold levels (D2cc ≤ 75 Gy EQD2) in some cases. This small, single-center analysis will be extended in a multicenter study.
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