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Pawałowski B, Ryczkowski A, Panek R, Sobocka-Kurdyk U, Graczyk K, Piotrowski T. Accuracy of the doses computed by the Eclipse treatment planning system near and inside metal elements. Sci Rep 2022; 12:5974. [PMID: 35396569 PMCID: PMC8993896 DOI: 10.1038/s41598-022-10072-8] [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: 01/27/2022] [Accepted: 03/25/2022] [Indexed: 11/09/2022] Open
Abstract
Metal artefacts degrade clinical image quality which decreases the confidence of using computed tomography (CT) for the delineation of key structures for treatment planning and leads to dose errors in affected areas. In this work, we investigated accuracy of doses computed by the Eclipse treatment planning system near and inside metallic elements for two different computation algorithms. An impact of CT metal artefact reduction methods on the resulting calculated doses has also been assessed. A water phantom including Gafchromic film and metal inserts was irradiated (max dose 5 Gy) using a 6 MV photon beam. Three materials were tested: titanium, alloy 600, and tungsten. The phantom CT images were obtained with the pseudo-monoenergetic reconstruction (PMR) and the iterative metal artefact reduction (iMAR). Image sets were used for dose calculation using an Eclipse treatment planning station (TPS). Monte Carlo (MC) simulations were used to predict the true dose distribution in the phantom allowing for comparison with doses measured by film and calculated by TPS. Measured and simulated percentage depth doses (PDDs) were not statistically different (p > 0.618). Regional differences were observed at edges of metallic objects (max 8% difference). However, PDDs simulated with and without film were statistically different (p < 0.002). PDDs calculated by the Acuros XB algorithm based on the dose-to-medium approach best matched the MC reference regardless of the CT reconstruction methods and inserts used (p > 0.078). PDDs obtained using other algorithms significantly differ from the MC values (p < 0.011). The Acuros XB algorithm with a dose-to-medium approach provides reliable dose calculation in all metal regions when using the Varian system. The inability of the AAA algorithm to model backscatter dose significantly limits its clinical application in the presence of metal. No significant impact on the dose calculation was found for a range of metal artefact reduction strategies.
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Affiliation(s)
- Bartosz Pawałowski
- Department of Medical Physics, Greater Poland Cancer Centre, Garbary 15, 61-866, Poznan, Poland.,Department of Technical Physics, Poznan University of Technology, Poznan, Poland
| | - Adam Ryczkowski
- Department of Medical Physics, Greater Poland Cancer Centre, Garbary 15, 61-866, Poznan, Poland.,Department of Electroradiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Rafał Panek
- Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK.,School of Medicine, University of Nottingham, Nottingham, UK
| | - Urszula Sobocka-Kurdyk
- Department of Medical Physics, Greater Poland Cancer Centre, Garbary 15, 61-866, Poznan, Poland.,Faculty of Health Sciences, Calisia University, Kalisz, Poland
| | - Kinga Graczyk
- Department of Medical Physics, Greater Poland Cancer Centre, Garbary 15, 61-866, Poznan, Poland
| | - Tomasz Piotrowski
- Department of Medical Physics, Greater Poland Cancer Centre, Garbary 15, 61-866, Poznan, Poland. .,Department of Electroradiology, Poznan University of Medical Sciences, Poznan, Poland.
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Le Fèvre C, Lacornerie T, Noël G, Antoni D. Management of metallic implants in radiotherapy. Cancer Radiother 2021; 26:411-416. [PMID: 34955412 DOI: 10.1016/j.canrad.2021.11.004] [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] [Indexed: 11/18/2022]
Abstract
The number of patients with metallic implant and treated with radiotherapy is constantly increasing. These hardware are responsible for the deterioration in the quality of the CT images used at each stage of the radiation therapy, during delineation, dosimetry and dose delivery. We present the update of the recommendations of the French society of oncological radiotherapy on the pros and cons of the different methods, existing and under evaluation, which limit the impact of metallic implants on the quality and safety of radiation treatments.
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Affiliation(s)
- C Le Fèvre
- Service de radiothérapie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France
| | - T Lacornerie
- Département de physique médicale, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - G Noël
- Service de radiothérapie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France; Université de Strasbourg, CNRS, IPHC UMR 7178, centre Paul-Strauss, Unicancer, 67000 Strasbourg, France
| | - D Antoni
- Service de radiothérapie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France; Université de Strasbourg, CNRS, IPHC UMR 7178, centre Paul-Strauss, Unicancer, 67000 Strasbourg, France.
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3
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Felisi M, Monti AF, Lizio D, Nici S, Pellegrini RG, Riga S, Bortolato B, Brambilla MG, Carbonini C, Abujami M, Carsana C, Sibio D, Potente C, Vanzulli A, Palazzi MF, Torresin A. MRI only in a patient with prostate cancer with bilateral metal hip prostheses: case study. TUMORI JOURNAL 2021; 107:NP41-NP44. [PMID: 33629653 DOI: 10.1177/0300891621997549] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To outline a practical method of performing prostate cancer radiotherapy in patients with bilateral metal hip prostheses with the standard resources available in a modern general hospital. The proposed workflow is based exclusively on magnetic resonance imaging (MRI) to avoid computed tomography (CT) artifacts. CASE DESCRIPTION This study concerns a 73-year-old man with bilateral hip prostheses with an elevated risk prostate cancer. Magnetic resonance images with assigned electron densities were used for planning purposes, generating a synthetic CT (sCT). Imaging acquisition was performed with an optimized Dixon sequence on a 1.5T MRI scanner. The images were contoured by autosegmentation software, based on an MRI database of 20 patients. The sCT was generated assigning averaged electron densities to each contour. Two volumetric modulated arc therapy plans, a complete arc and a partial one, where the beam entrances through the prostheses were avoided for about 50° on both sides, were compared. The feasibility of matching daily cone beam CT (CBCT) with MRI reference images was also tested by visual evaluations of different radiation oncologists. CONCLUSIONS The use of magnetic resonance images improved accuracy in targets and organs at risk (OARs) contouring. The complete arc plan was chosen because of 10% lower mean and maximum doses to prostheses with the same planning target volume coverage and OAR sparing. The image quality of the match between performed CBCTs and MRI was considered acceptable. The proposed method seems promising to improve radiotherapy treatments for this complex category of patients.
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Affiliation(s)
- Marco Felisi
- Medical Physics Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Angelo Filippo Monti
- Medical Physics Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Domenico Lizio
- Medical Physics Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Stefania Nici
- Medical Physics Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Stefano Riga
- Medical Physics Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Barbara Bortolato
- Radiotherapy Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Claudia Carbonini
- Medical Physics Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Mohammed Abujami
- Medical Physics Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Chiara Carsana
- Radiotherapy Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Daniela Sibio
- Radiotherapy Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Carmelina Potente
- Radiotherapy Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Angelo Vanzulli
- Radiology Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Alberto Torresin
- Medical Physics Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
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Halvorsen PH, Hariharan N, Morelli ZT, Iftimia IN. Modeling of kyphoplasty cement for accurate dose calculations. J Appl Clin Med Phys 2021; 22:261-272. [PMID: 33599374 PMCID: PMC7984498 DOI: 10.1002/acm2.13174] [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: 07/17/2020] [Revised: 11/30/2020] [Accepted: 12/29/2020] [Indexed: 12/01/2022] Open
Abstract
We have determined the optimal method for modeling kyphoplasty cement to enable accurate dose calculations in the Eclipse treatment planning system (TPS). The cement studied (Medtronic Kyphon HV‐R®) consists of 30% Barium, 68% polymethylmethacrylate (PMMA), and 2% benzoyl peroxide, formulated to be radiopaque with kV imaging systems. Neither Barium nor PMMA have a high physical density, resulting in different interaction characteristics for megavoltage treatment beams compared to kV imaging systems. This can lead to significant calculation errors if density mapping is performed using a standard CT number to density curve. To properly characterize the cement for dose calculation, we 3D printed a hemi‐cylindrical container to fit adjacent to a micro‐chamber insert for an anthropomorphic phantom, and filled the container with Kyphon cement. We CT scanned the combination, modeled the cement with multiple material assignments in the TPS, designed plans with different field sizes and beam geometry for five photon modes, and measured the doses for all plans. All photon energies show significant error in calculated dose when the cement is modeled based on the CT number. Of the material assignments we evaluated, polytetrafluoroethylene (PTFE) showed the best overall agreement with measurement. Calculated and measured doses agree within 3.5% for a 340‐degree arc technique (which averages transmission and scatter effects) with the Acuros XB algorithm and PTFE as the assigned material. To confirm that PTFE is a reasonable substitute for kyphoplasty cement, we performed measurements in a slab phantom using rectangular inserts of cement and PTFE, showing average agreement of all photon modes within 2%. Based on these findings, we conclude that the PTFE material assignment provides acceptable dose calculation accuracy for the AAA and Acuros XB photon algorithms in the Eclipse TPS. We recommend that the cement be delineated as a structure and assigned the PTFE material for accurate dose calculation.
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Affiliation(s)
- Per H Halvorsen
- Department of Radiation Oncology, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA, USA
| | - Navneeth Hariharan
- Department of Radiation Oncology, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA, USA
| | - Zackary T Morelli
- Department of Radiation Oncology, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA, USA
| | - Ileana N Iftimia
- Department of Radiation Oncology, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA, USA
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Rosado PH, Salata C, David MG, Mantuano A, Pickler A, Mota CL, de Almeida CE. Determination of the absorbed dose to water for medium-energy x-ray beams using Fricke dosimetry. Med Phys 2020; 47:5802-5809. [PMID: 32964481 DOI: 10.1002/mp.14473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/22/2020] [Accepted: 08/30/2020] [Indexed: 12/25/2022] Open
Abstract
PURPOSE For x-ray beams in the low and medium energy range, reference dosimetry is established in terms of air kerma. Fricke dosimetry has shown great potential in the absolute measurements of the absorbed dose to water for high-energy ranges. Therefore, the main purpose of this work was to compare the absorbed dose to water for medium-energy x-ray beams obtained through Fricke dosimetry with that obtained from the air kerma rate. METHODS To determine the absorbed dose to water using Fricke dosimetry, the polyethylene bags methodology was chosen. Fricke solution was irradiated at four different beam qualities. The absorbed dose to water values obtained using Fricke dosimetry were compared to those obtained using the standard protocol, using the Z-score. RESULTS Values of the Z-score were <2 for all measurements of absorbed dose to water, which means that the values obtained using Fricke dosimetry are equivalent to those obtained using the reference protocol. The combined standard uncertainty for the absorbed dose to water obtained by Fricke dosimetry was lower than that obtained with the ionization chamber. CONCLUSIONS Chemical dosimetry using a standard FeSO4 solution has been demonstrated to be a potential option as a standard for the quantity absorbed dose to water for medium kV x-ray qualities.
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Affiliation(s)
- Paulo Henrique Rosado
- Brazilian National Ionizing Radiation Metrology Laboratory, Radioprotection and Dosimetry Institute (IRD), Rio de Janeiro, Brazil.,Department of Medical and Research Facilities, National Nuclear Energy Authority (CNEN), Rio de Janeiro, Brazil
| | - Camila Salata
- Department of Medical and Research Facilities, National Nuclear Energy Authority (CNEN), Rio de Janeiro, Brazil.,Radiological Sciences Department, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Mariano Gazineu David
- Polytechnic Institute of the Rio de Janeiro State University (IPRJ/UERJ), Rio de Janeiro, Brazil
| | - Andrea Mantuano
- Radiological Sciences Department, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Arissa Pickler
- Radiological Sciences Department, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Carla Lemos Mota
- Radiological Sciences Department, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil.,Physics Department, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Carlos E de Almeida
- Radiological Sciences Department, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
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6
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La radiothérapie externe guidée par l’imagerie dans le cancer de la prostate ; comment, quand et pourquoi ? Cancer Radiother 2018; 22:586-592. [DOI: 10.1016/j.canrad.2018.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 06/29/2018] [Indexed: 12/14/2022]
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Huang JY, Followill DS, Howell RM, Liu X, Mirkovic D, Stingo FC, Kry SF. Approaches to reducing photon dose calculation errors near metal implants. Med Phys 2017; 43:5117. [PMID: 27587042 DOI: 10.1118/1.4960632] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Dose calculation errors near metal implants are caused by limitations of the dose calculation algorithm in modeling tissue/metal interface effects as well as density assignment errors caused by imaging artifacts. The purpose of this study was to investigate two strategies for reducing dose calculation errors near metal implants: implementation of metal-based energy deposition kernels in the convolution/superposition (C/S) dose calculation method and use of metal artifact reduction methods for computed tomography (CT) imaging. METHODS Both error reduction strategies were investigated using a simple geometric slab phantom with a rectangular metal insert (composed of titanium or Cerrobend), as well as two anthropomorphic phantoms (one with spinal hardware and one with dental fillings), designed to mimic relevant clinical scenarios. To assess the dosimetric impact of metal kernels, the authors implemented titanium and silver kernels in a commercial collapsed cone C/S algorithm. To assess the impact of CT metal artifact reduction methods, the authors performed dose calculations using baseline imaging techniques (uncorrected 120 kVp imaging) and three commercial metal artifact reduction methods: Philips Healthcare's o-mar, GE Healthcare's monochromatic gemstone spectral imaging (gsi) using dual-energy CT, and gsi with metal artifact reduction software (mars) applied. For the simple geometric phantom, radiochromic film was used to measure dose upstream and downstream of metal inserts. For the anthropomorphic phantoms, ion chambers and radiochromic film were used to quantify the benefit of the error reduction strategies. RESULTS Metal kernels did not universally improve accuracy but rather resulted in better accuracy upstream of metal implants and decreased accuracy directly downstream. For the clinical cases (spinal hardware and dental fillings), metal kernels had very little impact on the dose calculation accuracy (<1.0%). Of the commercial CT artifact reduction methods investigated, the authors found that o-mar was the most consistent method, resulting in either improved dose calculation accuracy (dental case) or little impact on calculation accuracy (spine case). gsi was unsuccessful at reducing the severe artifacts caused by dental fillings and had very little impact on calculation accuracy. gsi with mars on the other hand gave mixed results, sometimes introducing metal distortion and increasing calculation errors (titanium rectangular implant and titanium spinal hardware) but other times very successfully reducing artifacts (Cerrobend rectangular implant and dental fillings). CONCLUSIONS Though successful at improving dose calculation accuracy upstream of metal implants, metal kernels were not found to substantially improve accuracy for clinical cases. Of the commercial artifact reduction methods investigated, o-mar was found to be the most consistent candidate for all-purpose CT simulation imaging. The mars algorithm for gsi should be used with caution for titanium implants, larger implants, and implants located near heterogeneities as it can distort the size and shape of implants and increase calculation errors.
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Affiliation(s)
- Jessie Y Huang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030 and Graduate School of Biomedical Sciences, The University of Texas Health Science Center Houston, Houston, Texas 77030
| | - David S Followill
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030 and Graduate School of Biomedical Sciences, The University of Texas Health Science Center Houston, Houston, Texas 77030
| | - Rebecca M Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030 and Graduate School of Biomedical Sciences, The University of Texas Health Science Center Houston, Houston, Texas 77030
| | - Xinming Liu
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030 and Graduate School of Biomedical Sciences, The University of Texas Health Science Center Houston, Houston, Texas 77030
| | - Dragan Mirkovic
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030 and Graduate School of Biomedical Sciences, The University of Texas Health Science Center Houston, Houston, Texas 77030
| | - Francesco C Stingo
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030 and Graduate School of Biomedical Sciences, The University of Texas Health Science Center Houston, Houston, Texas 77030
| | - Stephen F Kry
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030 and Graduate School of Biomedical Sciences, The University of Texas Health Science Center Houston, Houston, Texas 77030
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8
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Zaorsky NG, Showalter TN, Ezzell GA, Nguyen PL, Assimos DG, D'Amico AV, Gottschalk AR, Gustafson GS, Keole SR, Liauw SL, Lloyd S, McLaughlin PW, Movsas B, Prestidge BR, Taira AV, Vapiwala N, Davis BJ. ACR Appropriateness Criteria ® external beam radiation therapy treatment planning for clinically localized prostate cancer, part I of II. Adv Radiat Oncol 2016; 2:62-84. [PMID: 28740916 PMCID: PMC5514238 DOI: 10.1016/j.adro.2016.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/12/2016] [Indexed: 12/24/2022] Open
Affiliation(s)
| | | | | | - Gary A Ezzell
- Mayo Clinic, Phoenix, Arizona (research author, contributing)
| | - Paul L Nguyen
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts (panel vice-chair)
| | - Dean G Assimos
- University of Alabama School of Medicine, Birmingham, Alabama (American Urological Association)
| | - Anthony V D'Amico
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts (American Society of Clinical Oncology)
| | | | | | | | | | - Shane Lloyd
- Huntsman Cancer Hospital, Salt Lake City, Utah
| | | | | | | | - Al V Taira
- Mills Peninsula Hospital, San Mateo, California
| | - Neha Vapiwala
- University of Pennsylvania, Philadelphia, Pennsylvania
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Falcinelli L, Palumbo I, Radicchia V, Arcidiacono F, Lancellotta V, Montesi G, Matrone F, Zucchetti C, Marcantonini M, Bini V, Aristei C. Prostate cancer: contouring target and organs at risk by kilovoltage and megavoltage CT and MRI in patients with and without hip prostheses. Br J Radiol 2015; 88:20150509. [PMID: 26462970 DOI: 10.1259/bjr.20150509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE In radiotherapy treatment, planning target volume and organs at risk are contoured on kilovoltage CT (kVCT) images. Unlike MR images, kVCT does not provide precise information on target volume extension. Since neither kVCT nor MRI may be suitable for contouring in patients with ferrous hip prostheses, this study evaluated whether megavoltage CT (MVCT) reduced interobserver variability. METHODS Two patients without hip prostheses and one patient (Patient 3) with hip prostheses were enrolled. Six radiation oncologists contoured prostate, rectum and bladder on kVCT (Patients 1 and 3), MRI (Patient 2) and MVCT images (Patient 3). MVCT was acquired with fine, normal and coarse modalities. Interobserver variability for each organ was analysed using conformity index (CI) and coefficient of variation (CV). RESULTS In patients without hip prostheses, CIs were higher in prostate contouring with MRI than with kVCT, indicating lower interobserver variability with MRI. Very slight variations were seen in rectum and bladder contouring. In the patient with hip prostheses (Patient 3), contouring on kVCT lowered CI and increased CV in the prostate, bladder and rectum. The differences were more marked in the prostate. Only fine modality MVCT reduced interobserver variability and only for the prostate. CONCLUSION Even though greater noise and less soft-tissue contrast increase contouring variability with MVCT than with kVCT, lack of artefacts on MVCT could provide better image definition by this modality in hip prosthesis patients in whom MRI is precluded. ADVANCES IN KNOWLEDGE We recommend the fine modality MVCT for contouring hip prostheses patients.
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Affiliation(s)
- Lorenzo Falcinelli
- 1 Department of Onco-Haematological and Gastroenterological Science, Radiation Oncology Division, Perugia General Hospital, Perugia, Italy
| | - Isabella Palumbo
- 2 Radiation Oncology Section, Department of Surgical and Biomedical Sciences, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Valentina Radicchia
- 2 Radiation Oncology Section, Department of Surgical and Biomedical Sciences, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Fabio Arcidiacono
- 2 Radiation Oncology Section, Department of Surgical and Biomedical Sciences, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Valentina Lancellotta
- 2 Radiation Oncology Section, Department of Surgical and Biomedical Sciences, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Giampaolo Montesi
- 2 Radiation Oncology Section, Department of Surgical and Biomedical Sciences, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Fabio Matrone
- 2 Radiation Oncology Section, Department of Surgical and Biomedical Sciences, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Claudio Zucchetti
- 3 Department of Imaging and Laboratory Diagnosis, Medical Physics Unit, Perugia General Hospital, Perugia, Italy
| | - Marta Marcantonini
- 3 Department of Imaging and Laboratory Diagnosis, Medical Physics Unit, Perugia General Hospital, Perugia, Italy
| | - Vittorio Bini
- 4 Internal Medicine, Endocrine and Metabolic Sciences Section, Perugia General Hospital, Perugia, Italy
| | - Cynthia Aristei
- 2 Radiation Oncology Section, Department of Surgical and Biomedical Sciences, University of Perugia and Perugia General Hospital, Perugia, Italy
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