Abdominal synthetic CT reconstruction with intensity projection prior for MRI-only adaptive radiotherapy

An MRI-only adaptive radiotherapy (ART) workflow is desirable for managing interfractional changes in anatomy, but producing synthetic CT (sCT) data through paired data-driven deep learning (DL) for abdominal dose calculations remains a challenge due to the highly variable presence of intestinal gas. We present the preliminary dosimetric evaluation of our novel approach to sCT reconstruction that is well suited to handling intestinal gas in abdominal MRI-only ART. We utilize a paired data DL approach enabled by the intensity projection prior, in which well-matching training pairs are created by propagating air from MRI to corresponding CT scans. Evaluations focus on two classes: patients with (1) little involvement of intestinal gas, and (2) notable differences in intestinal gas presence between corresponding scans. Comparisons between sCT-based plans and CT-based clinical plans for both classes are made at the first treatment fraction to highlight the dosimetric impact of the variable presence of intestinal gas. Class 1 patients ($n=13$) demonstrate differences in prescribed dose coverage of the PTV of $1.3 \pm 2.1\%$ between clinical plans and sCT-based plans. Mean DVH differences in all structures for Class 1 patients are found to be statistically insignificant. In Class 2 ($n=20$), target coverage is $13.3 \pm 11.0\%$ higher in the clinical plans and mean DVH differences are found to be statistically significant. Significant deviations in calculated doses arising from the variable presence of intestinal gas in corresponding CT and MRI scans may limit the effectiveness of adaptive dose escalation efforts. We have proposed a paired data-driven DL approach to sCT reconstruction for accurate dose calculations in abdominal ART enabled by the creation of a clinically unavailable training data set with well-matching representations of intestinal gas.