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Title: Variability of Gross Tumor Volume Delineation in Head-and-Neck Cancer Using PET/CT Fusion, Part II: The Impact of a Contouring Protocol

Abstract

The purpose of this study was to assess the efficacy of a gross tumor volume (GTV) contouring protocol on interobserver variability between 4 physicians in positron emission therapy/computed tomography (PET/CT) treatment planning of head-and-neck cancer. A GTV contouring protocol for PET/CT treatment planning was developed utilizing 4 stages: Preliminary contouring on CT alone, determination of appropriate PET windowing, accurate image registration, and modification of CT contouring with correctly formatted PET/CT display and rules for modality disagreement. Two neuroradiologists and 2 radiation oncologists (designated as A, B, C, and D, respectively) were given a tutorial of PET/CT coregistered imaging individualized to their skill level, which included a step-by-step explanation of the protocol with clinical examples. Opportunities for questions and hands-on practice were given. The physicians were asked to re-contour 16 head-and-neck patients from Part I on PET/CT fusion imaging. Differences in volume magnitude were analyzed for statistical significance by analysis of variance (ANOVA) and paired t-tests ({alpha} < 0.05). Volume overlap was analyzed for statistical significance using Wilcoxon signed-rank tests ({alpha} < 0.05). Volume overlap increased significantly from Part I to Part II (p < 0.05). One previously significant difference between physicians disappeared with the protocol in place. The mean fusionmore » volume of Physician C, however, remained significantly larger than that of Physician D (p < 0.01). This result is unchanged from Part I. The multidisciplinary contouring protocol significantly improved the coincidence of GTVs contoured by multiple physicians. The magnitudes of the volumes showed marginal improvement in consistency. Developing an institutional contouring protocol for PET/CT treatment planning is highly recommended to reduce interobserver variability.« less

Authors:
 [1];  [2];  [3]; ; ; ; ; ; ;  [4];  [2];  [2];  [2]
  1. St. Vincent's Comprehensive Cancer Center, New York, NY (United StateS)
  2. (United States)
  3. (United States) and Mount Sinai Medical Center, New York, NY (United States), E-mail: aberson@aptiumoncology.com
  4. St. Vincent's Comprehensive Cancer Center, New York, NY (United States)
Publication Date:
OSTI Identifier:
21180438
Resource Type:
Journal Article
Resource Relation:
Journal Name: Medical Dosimetry; Journal Volume: 34; Journal Issue: 1; Other Information: DOI: 10.1016/j.meddos.2007.08.003; PII: S0958-3947(07)00156-2; Copyright (c) 2009 Elsevier Science B.V., Amsterdam, The Netherlands, All rights reserved; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; CARCINOMAS; COMPUTERIZED TOMOGRAPHY; HEAD; IMAGES; MEDICAL PERSONNEL; NECK; NEOPLASMS; PROTON COMPUTED TOMOGRAPHY

Citation Formats

Berson, Anthony M., St. Vincent's Hospital, New York, NY, New York Medical College, Valhalla, NY, Stein, Nicholas F., Riegel, Adam C., Destian, Sylvie, Ng, Tracy, Tena, Lawrence B., Mitnick, Robin J., Heiba, Sherif, St. Vincent's Hospital, New York, NY, New York Medical College, Valhalla, NY, and and Mount Sinai Medical Center, New York, NY. Variability of Gross Tumor Volume Delineation in Head-and-Neck Cancer Using PET/CT Fusion, Part II: The Impact of a Contouring Protocol. United States: N. p., 2009. Web. doi:10.1016/j.meddos.2007.08.003.
Berson, Anthony M., St. Vincent's Hospital, New York, NY, New York Medical College, Valhalla, NY, Stein, Nicholas F., Riegel, Adam C., Destian, Sylvie, Ng, Tracy, Tena, Lawrence B., Mitnick, Robin J., Heiba, Sherif, St. Vincent's Hospital, New York, NY, New York Medical College, Valhalla, NY, & and Mount Sinai Medical Center, New York, NY. Variability of Gross Tumor Volume Delineation in Head-and-Neck Cancer Using PET/CT Fusion, Part II: The Impact of a Contouring Protocol. United States. doi:10.1016/j.meddos.2007.08.003.
Berson, Anthony M., St. Vincent's Hospital, New York, NY, New York Medical College, Valhalla, NY, Stein, Nicholas F., Riegel, Adam C., Destian, Sylvie, Ng, Tracy, Tena, Lawrence B., Mitnick, Robin J., Heiba, Sherif, St. Vincent's Hospital, New York, NY, New York Medical College, Valhalla, NY, and and Mount Sinai Medical Center, New York, NY. 2009. "Variability of Gross Tumor Volume Delineation in Head-and-Neck Cancer Using PET/CT Fusion, Part II: The Impact of a Contouring Protocol". United States. doi:10.1016/j.meddos.2007.08.003.
@article{osti_21180438,
title = {Variability of Gross Tumor Volume Delineation in Head-and-Neck Cancer Using PET/CT Fusion, Part II: The Impact of a Contouring Protocol},
author = {Berson, Anthony M. and St. Vincent's Hospital, New York, NY and New York Medical College, Valhalla, NY and Stein, Nicholas F. and Riegel, Adam C. and Destian, Sylvie and Ng, Tracy and Tena, Lawrence B. and Mitnick, Robin J. and Heiba, Sherif and St. Vincent's Hospital, New York, NY and New York Medical College, Valhalla, NY and and Mount Sinai Medical Center, New York, NY},
abstractNote = {The purpose of this study was to assess the efficacy of a gross tumor volume (GTV) contouring protocol on interobserver variability between 4 physicians in positron emission therapy/computed tomography (PET/CT) treatment planning of head-and-neck cancer. A GTV contouring protocol for PET/CT treatment planning was developed utilizing 4 stages: Preliminary contouring on CT alone, determination of appropriate PET windowing, accurate image registration, and modification of CT contouring with correctly formatted PET/CT display and rules for modality disagreement. Two neuroradiologists and 2 radiation oncologists (designated as A, B, C, and D, respectively) were given a tutorial of PET/CT coregistered imaging individualized to their skill level, which included a step-by-step explanation of the protocol with clinical examples. Opportunities for questions and hands-on practice were given. The physicians were asked to re-contour 16 head-and-neck patients from Part I on PET/CT fusion imaging. Differences in volume magnitude were analyzed for statistical significance by analysis of variance (ANOVA) and paired t-tests ({alpha} < 0.05). Volume overlap was analyzed for statistical significance using Wilcoxon signed-rank tests ({alpha} < 0.05). Volume overlap increased significantly from Part I to Part II (p < 0.05). One previously significant difference between physicians disappeared with the protocol in place. The mean fusion volume of Physician C, however, remained significantly larger than that of Physician D (p < 0.01). This result is unchanged from Part I. The multidisciplinary contouring protocol significantly improved the coincidence of GTVs contoured by multiple physicians. The magnitudes of the volumes showed marginal improvement in consistency. Developing an institutional contouring protocol for PET/CT treatment planning is highly recommended to reduce interobserver variability.},
doi = {10.1016/j.meddos.2007.08.003},
journal = {Medical Dosimetry},
number = 1,
volume = 34,
place = {United States},
year = 2009,
month = 4
}
  • Purpose: To assess the need for gross tumor volume (GTV) delineation protocols in head-and-neck cancer (HNC) treatment planning by use of positron emission tomography (PET)/computed tomography (CT) fusion imaging. Assessment will consist of interobserver and intermodality variation analysis. Methods and Materials: Sixteen HNC patients were accrued for the study. Four physicians (2 neuroradiologists and 2 radiation oncologists) contoured GTV on 16 patients. Physicians were asked to contour GTV on the basis of the CT alone, and then on PET/CT fusion. Statistical analysis included analysis of variance for interobserver variability and Student's paired sample t test for intermodality and interdisciplinary variability.more » A Boolean pairwise analysis was included to measure degree of overlap. Results: Near-significant variation occurred across physicians' CT volumes (p = 0.09) and significant variation occurred across physicians' PET/CT volumes (p = 0.0002). The Boolean comparison correlates with statistical findings. One radiation oncologist's PET/CT fusion volumes were significantly larger than his CT volumes (p < 0.01). Conversely, the other radiation oncologist's CT volumes tended to be larger than his fusion volumes (p = 0.06). No significant interdisciplinary variation was seen. Significant disagreement occurred between radiation oncologists. Conclusion: Significant differences in GTV delineation were found between multiple observers contouring on PET/CT fusion. The need for delineation protocol has been confirmed.« less
  • Purpose: To study anatomic biologic contouring (ABC), using a previously described distinct halo, to unify volume contouring methods in treatment planning for head and neck cancers. Methods and Materials: Twenty-five patients with head and neck cancer at various sites were planned for radiation therapy using positron emission tomography/computed tomography (PET/CT). The ABC halo was used in all PET/CT scans to contour the gross tumor volume (GTV) edge. The CT-based GTV (GTV-CT) and PET/CT-based GTV (GTV-ABC) were contoured by two independent radiation oncologists. Results: The ABC halo was observed in all patients studied. The halo had a standard unit value ofmore » 2.19 {+-} 0.28. The mean halo thickness was 2.02 {+-} 0.21 mm. Significant volume modification ({>=}25%) was seen in 17 of 25 patients (68%) after implementation of GTV-ABC. Concordance among observers was increased with the use of the halo as a guide for GTV determination: 6 patients (24%) had a {<=}10% volume discrepancy with CT alone, compared with 22 (88%) with PET/CT (p < 0.001). Interobserver variability decreased from a mean GTV difference of 20.3 cm{sup 3} in CT-based planning to 7.2 cm{sup 3} in PET/CT-based planning (p < 0.001). Conclusions: Using the 'anatomic biologic halo' to contour GTV in PET/CT improves consistency among observers. The distinctive appearance of the described halo and its presence in all of the studied tumors make it attractive for GTV contouring in head and neck tumors. Additional studies are needed to confirm the correlation of the halo with presence of malignant cells.« less
  • Tumor boundary delineation using positron emission tomography (PET) is a promising tool for radiation therapy applications. In this study we quantify the uncertainties in tumor boundary delineation as a function of the reconstruction method, smoothing, and lesion size in head and neck cancer patients using FDG-PET images and evaluate the dosimetric impact on radiotherapy plans. FDG-PET images were acquired for eight patients with a GE Advance PET scanner. In addition, a 20 cm diameter cylindrical phantom with six FDG-filled spheres with volumes of 1.2 to 26.5 cm{sup 3} was imaged. PET emission scans were reconstructed with the OSEM and FBPmore » algorithms with different smoothing parameters. PET-based tumor regions were delineated using an automatic contouring function set at progressively higher threshold contour levels and the resulting volumes were calculated. CT-based tumor volumes were also contoured by a physician on coregistered PET/CT patient images. The intensity value of the threshold contour level that returns 100% of the actual volume, I{sub V100}, was measured. We generated intensity-modulated radiotherapy (IMRT) plans for an example head and neck patient, treating 66 Gy to CT-based gross disease and 54 Gy to nodal regions at risk, followed by a boost to the FDG-PET-based tumor. The volumes of PET-based tumors are a sensitive function of threshold contour level for all patients and phantom datasets. A 5% change in threshold contour level can translate into a 200% increase in volume. Phantom data indicate that I{sub V100} can be set as a fraction, f, of the maximum measured uptake. Fractional threshold values in the cylindrical water phantom range from 0.23 to 0.51. Both the fractional threshold and the threshold-volume curve are dependent on lesion size, with lesions smaller than approximately 5 cm{sup 3} displaying a more pronounced sensitivity and larger fractional threshold values. The threshold-volume curves and fractional threshold values also depend on the reconstruction algorithm and smoothing filter with more smoothing requiring a higher fractional threshold contour level. The threshold contour level affects the tumor size, and therefore the ultimate boost dose that is achievable with IMRT. In an example head and neck IMRT plan, the D95 of the planning target volume decreased from 7770 to 7230 cGy for 42% vs 55% contour threshold levels. PET-based tumor volumes are strongly affected by the choice of threshold level. This can have a significant dosimetric impact. The appropriate threshold level depends on lesion size and image reconstruction parameters. These effects should be carefully considered when using PET contour and/or volume information for radiotherapy applications.« less
  • Purpose: Positron emission tomography/computed tomography (PET/CT) is increasingly used for delineating gross tumor volume (GTV) in non-small-cell lung cancer (NSCLC). The methodology for contouring tumor margins remains controversial. We developed a rigorous visual protocol for contouring GTV that uses all available clinical information and studied its reproducibility in patients from a prospective PET/CT planning trial. Methods and Materials: Planning PET/CT scans from 6 consecutive patients were selected. Six 'observers' (two radiation oncologists, two nuclear medicine physicians, and two radiologists) contoured GTVs for each patient using a predefined protocol and subsequently recontoured 2 patients. For the estimated GTVs and axial distances,more » least-squares means for each observer and for each case were calculated and compared, using the F test and pairwise t-tests. In five cases, tumor margins were also autocontoured using standardized uptake value (SUV) cutoffs of 2.5 and 3.5 and 40% SUV{sub max}. Results: The magnitude of variation between observers was small relative to the mean (coefficient of variation [CV] = 3%), and the total variation (intraclass correlation coefficient [ICC] = 3%). For estimation of superior/inferior (SI), left/right (LR), and anterior/posterior (AP) borders of the GTV, differences between observers were also small (AP, CV = 2%, ICC = 0.4%; LR, CV = 6%, ICC = 2%; SI, CV 4%, ICC = 2%). GTVs autocontoured generated using SUV 2.5, 3.5, and 40% SUV{sub max} differed widely in each case. An SUV contour of 2.5 was most closely correlated with the mean GTV defined by the human observers. Conclusions: Observer variation contributed little to total variation in the GTV and axial distances. A visual contouring protocol gave reproducible results for contouring GTV in NSCLC.« less
  • Purpose: To compare the gross tumor volume (GTV) identified on CT to that obtained from fluorodeoxyglucose (FDG) positron emission tomography (PET) and determine the differences in volume and dose coverage of the PET-GTV when the CT-GTV is used for radiotherapy planning. Methods and Materials: A total of 40 patients with intact squamous cell carcinoma arising in the head-and-neck region underwent intensity-modulated radiotherapy (IMRT) at one department. All patients underwent CT simulation for treatment planning followed by PET-CT in the treatment position. CT simulation images were fused to the CT component of the PET-CT images. The GTV using the CT simulationmore » images was contoured (CT-GTV), as was the GTV based on the PET scan (PET-GTV). The IMRT plans were obtained using the CT-GTV. Results: The PET-GTV was smaller, the same size, and larger than the CT-GTV in 30 (75%), 3 (8%), and 7 (18%) cases respectively. The median PET-GTV and CT-GTV volume was 20.3 cm{sup 3} (range, 0.2-294) and 37.2 cm{sup 3} (range, 2-456), respectively. The volume of PET-GTV receiving at least 95% of the prescribed dose was 100% in 20 (50%), 95-99% in 10 (25%), 90-94% in 3 (8%), 85-89% in 1 (3%), 80-84% in 2 (5%), 75-79% in 1 (3%), and <75% in 3 (8%) cases. The minimal dose received by 95% of the PET-GTV was {>=}100% in 19 (48%), 95-99% in 11 (28%), 90-94% in 5 (13%), 85-89% in 2 (5%), and <75% in 3 (8%) cases. Conclusion: The PET-GTV was larger than the CT-GTV in 18% of cases. In approximately 25% of patients with intact head-and-neck cancer treated using IMRT, the volume of PET-GTV receiving at least 95% of the prescribed dose and minimal dose received by 95% of the PET-GTV were less than optimal.« less