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MRI-only simulation for head and neck (HN) radiotherapy (RT) could allow for single-image modality planning with excellent soft tissue contrast. In the MRI-only simulation workflow, synthetic CTs (sCTs) are generated from MRI to provide electron density information for dose calculation. Bone/air regions produce little MRI signal which could lead to electron density misclassification in sCTs. Establishing the dosimetric impact of this error could inform quality assurance (QA) procedures using MRI-only RT planning. In this study we quantify differences in Hounsfield Unit (HU) values between paired CT/ sCTs of HN cancer patients and investigate the dosimetric impact on clinical treatment plans. Fourteen patients with head and neck cancer undergoing same-day CT and 3T MRI simulation were retrospectively identified. MRIs were deformed to the CT using multimodal deformable image registration. SCTs were generated from T1w DIXON MRI using a commercially available deep learning-based generator (MRIplanner, Spectronics). Tissue voxel assignment was quantified by creating a CT-derived HU threshold contour. CT/sCT HU differences for anatomical/target contours and tissue classification regions including air (<-250HU), adipose tissue (–250HU to -51HU), soft tissue (-50HU to 199HU), spongy (200HU to 499HU) and cortical bone (> 500HU) were quantified. T-test was used to determine if sCT/CT HU differences were significant. The frequency of structures that had a HU difference >70HU (the CT window-width setting for intra-cranial structures) was computed to establish structure classification accuracy. Clinical IMRT treatment plans created on CTs were retrospectively recalculated on sCT images using compared using the gamma metric. The mean ratio of sCT HUs relative to CT for air, adipose tissue, soft tissue, spongy and cortical bone were 1.7±0.3, 1.1±0.1, 1.0±0.1, 0.9±0.1 and 0.8±0.1 (value of 1 indicates perfect agreement). T-tests (significance set at t = 0.05) identified differences in HU values for air, spongy and cortical bone in sCT images compared to CT. The structures with sCT/CT HU differences > 70HU were the L/R cochlea and mandible, occurring in >78% of the tested cohort. These structures contain dense bone/air interfaces. Plans recalculated on sCTs yielded global/local gamma pass rates of 98.7%±1.2% (3mm,3%) and 95.5%±2.5% (1mm,1%). Mean differences in D95, D50, D10 and D2 dose volume histogram (DVH) metrics for organ-at-risk (OAR) and planning tumor volumes (PTV) were 0.8%±1.5% and 2.1% ± 1.2% respectively. In this cohort, HU differences in sCTs were observed but did not translate into a reduction in gamma pass rates and OAR/PTV DVH metrics. The acquisition of additional training data such as ultrashort echo time MRI could improve bone/air contrast and reduce bone/air sCT misclassifications. Further studies will establish the variation in sCT dosimetric accuracy using a larger retrospective cohort to inform QA limits on clinical sCT usage. [ABSTRACT FROM AUTHOR]

To demonstrate whether incorporating a pre-measured breathing motion model into algebraic cone-beam CT (CBCT) reconstruction could improve daily target imaging for radiotherapy delivery of lung tumors. We employed our clinic's 5DCT simulation technique to generate the breathing motion model. 5DCT provides a voxel-by-voxel representation of breathing motion as a function of breathing amplitude and rate, and the motion model was used to characterize the breathing motion during CBCT acquisition. We acquired CBCT projections before treatment and simultaneously acquired a breathing amplitude signal using a respiratory bellows. The 5DCT reference image was registered to the CBCT geometry using a rigid registration of the spine. To enable the use of the 5DCT motion model on the CBCT data, a correspondence between the simulation and CBCT surrogates needed to be made. The breathing surrogates of the simulation were correlated with the CBCT using the diaphragm shadow in the CBCT projections and the 5DCT reference image deformed using the motion model. By adjusting the 5DCT model breathing amplitude, the diaphragm shadow moved until the CBCT projection and 5DCT diaphragm shadows overlapped, yielding the correspondence between the two surrogates such that the 5DCT motion model could be directly applied to the CBCT reconstruction. To reconstruct the CBCT image, we modified the motion-compensated simultaneous algebraic reconstruction technique (MC-SART) by introducing the aligned and scaled 5DCT motion model parameters. The modified MC-SART compared the raw projections to corresponding model-generated projections with various levels of binning. To quantify the 5DCT model's ability to describe the breathing motion during the CBCT, we reconstructed the CBCT dividing the breathing amplitude into 1, 2, 4 and 8 bins. We examined the corresponding sharpness of the diaphragm to see if the diaphragm boundary continuously sharpened with increasing bins. We found that the diaphragm appeared most blurred when only 1 amplitude bin was used, appearing sharper as bins were added. At 8 bins, the diaphragm boundary was only 2 voxels, consistent with typical breath-hold CT reconstruction. This demonstrated that the motion model from the CT simulation could quantitatively track breathing motion during the CBCT. However, while the diaphragm appeared sharper, the reconstructed images with increasing bins also had poorer image contrast. We have shown that using a previously determined breathing motion model with algebraic reconstruction can improve image sharpness. We will expand the current study to more patients and fractions and develop techniques to improve image contrast. However, since the purpose of this approach will be to localize lung tumors and characterize their motion at the treatment table, the image contrast may be sufficient. We will also compare our approach to published 4DCT approaches to determine if ours better manages irregular breathing. [ABSTRACT FROM AUTHOR]