title: Agreement among RTOG sarcoma radiation oncologists in contouring suspicious peritumoral edema for preoperative radiation therapy of soft tissue sarcoma of the extremity.
abstract: OBJECTIVE
  Peritumoral edema may harbor sarcoma cells. The extent of suspicious edema (SE) included in the treatment volume is subject to clinical judgment, balancing the risk of missing tumor cells with excess toxicity. Our goal was to determine variability in SE delineation by sarcoma radiation oncologists (RO).
  
  
  METHODS
  Twelve expert ROs were provided with T1 gadolinium and T2-weighted MR images of 10 patients with high-grade extremity soft-tissue sarcoma. Gross tumor volume, clinical target volume (CTV)3cm (3 cm longitudinal and 1.5 cm radial margin), and CTV2cm (2 cm longitudinal and 1 cm radial margin) were contoured by a single observer. Suspicious peritumoral edema, defined as abnormal signal on T2 images, was independently delineated by all 12 ROs. Contouring agreement was analyzed using the simultaneous truth and performance level estimation (STAPLE) algorithm and kappa statistics.
  
  
  RESULTS
  The mean volumes of GTV, CTV2cm, and CTV3cm were, respectively, 130 cm(3) (7-413 cm(3)), 280 cm(3) and 360 cm(3). The mean consensus volume computed using the STAPLE algorithm at 95% confidence interval was 188 cm(3) (24-565 cm(3)) with a substantial overall agreement corrected for chance (mean kappa = 0.71; range: 0.32-0.87). The minimum, maximum, and mean volume of SE (excluding the GTV) were 4, 182, and 58 cm(3) (representing a median of 29% of the GTV volume). The median volume of SE not included in the CTV2cm and in the CTV3cm was 5 and 0.3 cm(3), respectively. There were 3 large tumors with >30 cm(3) of SE not included in the CTV3cm volume.
  
  
  CONCLUSIONS
  Despite the fact that SE would empirically seem to be a more subjective volume, a substantial or near-perfect interobserver agreement was observed in SE delineation in most cases with high-grade soft-tissue sarcomas of the extremity. A median of 97% of the consensus SE is within the CTV2cm (99.8% within the CTV3cm). In a minority of cases, however, significant expansion of the CTVs is required to cover SE.
authors.affiliation: Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.
authors.forename: Houda
authors.initials: H
authors.lastname: Bahig
authors.forename: David
authors.initials: D
authors.lastname: Roberge
authors.forename: Walter
authors.initials: W
authors.lastname: Bosch
authors.forename: William
authors.initials: W
authors.lastname: Levin
authors.forename: Ivy
authors.initials: I
authors.lastname: Petersen
authors.forename: Michael
authors.initials: M
authors.lastname: Haddock
authors.forename: Carolyn
authors.initials: C
authors.lastname: Freeman
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Delaney
authors.forename: Ross A
authors.initials: RA
authors.lastname: Abrams
authors.forename: Danny J
authors.initials: DJ
authors.lastname: Indelicato
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Baldini
authors.forename: Ying
authors.initials: Y
authors.lastname: Hitchcock
authors.forename: David G
authors.initials: DG
authors.lastname: Kirsch
authors.forename: Kevin R
authors.initials: KR
authors.lastname: Kozak
authors.forename: Aaron
authors.initials: A
authors.lastname: Wolfson
authors.forename: Dian
authors.initials: D
authors.lastname: Wang
mesh_terms: D000465:Algorithms; D004487:Edema / Q000175:diagnosis*; D005121:Extremities; D005682:Gadolinium; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods; D018787:Radiation Oncology; D011868:Radioisotopes; D012509:Sarcoma / Q000175:diagnosis* / Q000473:pathology; D012983:Soft Tissue Neoplasms / Q000175:diagnosis* / Q000473:pathology; D047368:Tumor Burden
chemical_list: D011868:Radioisotopes; D005682:Gadolinium