Abstract
BackgroundThe delineation of pancreatic tumors on CT is challenging. In this study, we quantified the interobserver variation for pancreatic tumor delineation on 3DCT as well as on 4DCT.MethodsEight observers (radiation oncologists) from six institutions delineated pancreatic tumors of four patients with (borderline) resectable pancreatic cancer. The study consisted of two stages. In the 3DCT-stage, the gross tumor volume (GTV) was delineated on a contrast-enhanced scan. In the 4DCT-stage, the internal GTV (iGTV) was delineated, accounting for the respiratory motion. We calculated the volumes of the (i)GTV, the overlap of the delineated volumes (expressed as generalized conformity index: CIgen), the local observer variation (local standard deviation: SD) and the overall observer variation (overall SD). We compared these results between GTVs and iGTVs. Additionally, observers were asked to fill out a questionnaire concerning the difficulty of the delineation and their experience in delineating pancreatic tumors.ResultsThe ratios of the largest to the smallest delineated GTV and iGTV within the same patient were 6.8 and 16.5, respectively. As the iGTV incorporates the GTV during all respiratory phases, the mean volumes of the iGTV (40.07 cm3) were larger than those of the GTV (29.91 cm3). For all patients, CIgen was larger for the iGTV than for the GTV. The mean overall observer variation (root-mean-square of all local SDs over four patients) was 0.63 cm and 0.80 cm for GTV and iGTV, respectively. The largest local observer variations were seen close to biliary stents and suspicious pathological enlarged lymph nodes, as some observers included them and some did not. This variation was more pronounced for the iGTV than for the GTV. The observers rated the 3DCT-stage and 4DCT-stage equally difficult and treated on average three to four pancreatic cancer patients per year.ConclusionsA considerable interobserver variation in delineation of pancreatic tumors was observed. This variation was larger for 4D than for 3D delineation. The largest local observer variation was found around biliary stents and suspicious pathological enlarged lymph nodes.
Highlights
The delineation of pancreatic tumors on Computed tomography (CT) is challenging
A fourdimensional CT (4DCT) scan is increasingly used to account for tumor motion during respiration [1, 2], for example combined with the internal target volume (ITV) [5] or mid-ventilation approach [6]
An additional planning target volume (PTV) margin is added, to account for remaining set-up uncertainties. This PTV margin can be smaller compared with 3DCT delineation since respiratory motion uncertainty is accounted for in this 4D approach. In both the 3DCT and 4DCT approaches it is important that appropriate margin size is used as too small a margin leads to under-treatment of the target volume whereas too large a margin leads to unnecessarily high doses to the Organ at risk (OAR)
Summary
The delineation of pancreatic tumors on CT is challenging. In this study, we quantified the interobserver variation for pancreatic tumor delineation on 3DCT as well as on 4DCT. The aim of radiotherapy is delivering a high radiation dose to the tumor while minimizing the dose to organs at risk (OARs) For pancreatic tumors, this is challenging due to day-to-day position variation, respiratory motion, and uncertainties in delineation of the tumor [1,2,3,4]. This PTV margin can be smaller compared with 3DCT delineation since respiratory motion uncertainty is accounted for in this 4D approach In both the 3DCT and 4DCT approaches it is important that appropriate margin size is used as too small a margin leads to under-treatment of the target volume whereas too large a margin leads to unnecessarily high doses to the OARs. The CTV or iCTV to PTV margins currently used to account for the delineation uncertainties in pancreatic cancer are largely based on assumptions of these uncertainties. To investigate whether these assumptions are correct we performed a delineation study
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