title: Reduction of observer variation using matched CT-PET for lung cancer delineation: a three-dimensional analysis.
abstract: OBJECTIVE
  Target delineation using only CT information introduces large geometric uncertainties in radiotherapy for lung cancer. Therefore, a reduction of the delineation variability is needed. The impact of including a matched CT scan with 2-[18F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) and adaptation of the delineation protocol and software on target delineation in lung cancer was evaluated in an extensive multi-institutional setting and compared with the delineations using CT only.
  
  
  METHODS
  The study was separated into two phases. For the first phase, 11 radiation oncologists (observers) delineated the gross tumor volume (GTV), including the pathologic lymph nodes of 22 lung cancer patients (Stages I-IIIB) on CT only. For the second phase (1 year later), the same radiation oncologists delineated the GTV of the same 22 patients on a matched CT-FDG-PET scan using an adapted delineation protocol and software (according to the results of the first phase). All delineated volumes were analyzed in detail. The observer variation was computed in three dimensions by measuring the distance between the median GTV surface and each individual GTV. The variation in distance of all radiation oncologists was expressed as a standard deviation. The observer variation was evaluated for anatomic regions (lung, mediastinum, chest wall, atelectasis, and lymph nodes) and interpretation regions (agreement and disagreement; i.e., >80% vs. <80% of the radiation oncologists delineated the same structure, respectively). All radiation oncologist-computer interactions were recorded and analyzed with a tool called "Big Brother."
  
  
  RESULTS
  The overall three-dimensional observer variation was reduced from 1.0 cm (SD) for the first phase (CT only) to 0.4 cm (SD) for the second phase (matched CT-FDG-PET). The largest reduction in the observer variation was seen in the atelectasis region (SD 1.9 cm reduced to 0.5 cm). The mean ratio between the common and encompassing volume was 0.17 and 0.29 for the first and second phases, respectively. For the first phase, the common volume was 0 in 4 patients (i.e., no common point for all GTVs). In the second phase, the common volume was always >0. For all anatomic regions, the interpretation differences among the radiation oncologists were reduced. The amount of disagreement was 45% and 18% for the first and second phase, respectively. Furthermore, the mean delineation time (12 vs. 16 min, p<0.001) and mean number of corrections (25 vs. 39, p<0.001) were reduced in the second phase compared with the first phase.
  
  
  CONCLUSIONS
  For high-precision radiotherapy, the delineation of lung target volumes using only CT introduces too great a variability among radiation oncologists. Implementing matched CT-FDG-PET and adapted delineation protocol and software reduced observer variation in lung cancer delineation significantly with respect to CT only. However, the remaining observer variation was still large compared with other geometric uncertainties (setup variation and organ motion).
authors.affiliation: The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, and Radboud University Nijmegen, The Netherlands.
authors.forename: Roel J H M
authors.initials: RJ
authors.lastname: Steenbakkers
authors.forename: Joop C
authors.initials: JC
authors.lastname: Duppen
authors.forename: Isabelle
authors.initials: I
authors.lastname: Fitton
authors.forename: Kirsten E I
authors.initials: KE
authors.lastname: Deurloo
authors.forename: Lambert J
authors.initials: LJ
authors.lastname: Zijp
authors.forename: Emile F I
authors.initials: EF
authors.lastname: Comans
authors.forename: Apollonia L J
authors.initials: AL
authors.lastname: Uitterhoeve
authors.forename: Patrick T R
authors.initials: PT
authors.lastname: Rodrigus
authors.forename: Gijsbert W P
authors.initials: GW
authors.lastname: Kramer
authors.forename: Johan
authors.initials: J
authors.lastname: Bussink
authors.forename: Katrien
authors.initials: K
authors.lastname: De Jaeger
authors.forename: José S A
authors.initials: JS
authors.lastname: Belderbos
authors.forename: Peter J C M
authors.initials: PJ
authors.lastname: Nowak
authors.forename: Marcel
authors.initials: M
authors.lastname: van Herk
authors.forename: Coen R N
authors.initials: CR
authors.lastname: Rasch
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003936:Diagnosis, Computer-Assisted; D005260:Female; D019788:Fluorodeoxyglucose F18 / Q000627:therapeutic use; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging; D008175:Lung Neoplasms / Q000000981:diagnostic imaging*; D008198:Lymph Nodes / Q000000981:diagnostic imaging; D008297:Male; D008482:Mediastinum / Q000000981:diagnostic imaging; D008875:Middle Aged; D015588:Observer Variation; D019275:Radiopharmaceuticals / Q000627:therapeutic use; D035441:Thoracic Wall / Q000000981:diagnostic imaging; D014055:Tomography, Emission-Computed / Q000379:methods*; D014057:Tomography, X-Ray Computed / Q000379:methods*
chemical_list: D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18