title: A novel surrogate to identify anatomical changes during radiotherapy of head and neck cancer patients.
abstract: OBJECTIVE
  To develop a novel method to monitor external anatomical changes in head and neck cancer patients in order to triage possible adaptive radiotherapy needs.
  
  
  METHODS
  The presented approach aims to provide information on internal anatomical changes based on variations observed in external anatomy. Setup Cone Beam Computed Tomography (CBCT) images are processed to produce an accurate external contour of the patient's skin. After registering the CBCTs to the reference planning CT, the external contours from each CBCT are transferred to the initial - first week - CBCT. Contour radii, defined as the distances between an external contour and the isocenter projection in each CBCT slice, are calculated for each scan over the full 360 degrees. The changes in external anatomy are then quantified by the difference in radial distance between the external contours of any secondary CBCT relative to the initial CBCT. Finally, the radial difference is displayed in cylindrical coordinates as a 2D intensity map to highlight regions of interests with significant changes. Weekly CBCT scans from 15 head and neck patients were retrospectively analyzed to demonstrate the utility of this approach as a proof of principle. External changes suggested by the 2D radial difference map of an example patient after 23 fractions were then correlated with the changes in the gross tumor volumes and organs at risks. The resulting dosimetric effects were evaluated. An interactive standalone software application has been developed to facilitate the generation and the interpretation of the 2D intensity map.
  
  
  RESULTS
  The 2D radial difference maps provided qualitative and quantitative information, such as the location and the magnitude of external contour changes and the rate at which these deviations occur. Out of the 15 patients, 10 presented clear evidence of general external volume shrinkage due to weight loss, and nine patients had at least one site of local shrinkage. Only two patients showed no signs of anatomical change during their entire treatment course. For the example patient, the mean (±σ) radial difference was 6.7 (±3.0) mm for the left parotid and 7.3 (±2.5) mm for the right parotid. The mean dose to the left and right parotids increased from 20.1 Gy to 30 Gy and from 16.3 Gy to 29.6 Gy, respectively.
  
  
  CONCLUSIONS
  This novel method provides an efficient tool to visualize 3D external anatomical changes on a single 2D map. It quickly pinpoints the location of differences in anatomy during the course of radiotherapy, which can help physicians determine if a treatment plan needs to be adapted. The interactive graphic user interface developed in this study will be evaluated in an adaptive radiotherapy workflow for head and neck patients in a future prospective trial.
authors.affiliation: Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, 60153, USA.
authors.forename: Sébastien A A
authors.initials: SA
authors.lastname: Gros
authors.affiliation: Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, 60153, USA.
authors.forename: William
authors.initials: W
authors.lastname: Xu
authors.affiliation: Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, 60153, USA.
authors.forename: John C
authors.initials: JC
authors.lastname: Roeske
authors.affiliation: Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, 60153, USA.
authors.forename: Mehe
authors.initials: M
authors.lastname: Choi
authors.affiliation: Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, 60153, USA.
authors.forename: Bahman
authors.initials: B
authors.lastname: Emami
authors.affiliation: Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, 60153, USA.
authors.forename: Murat
authors.initials: M
authors.lastname: Surucu
mesh_terms: D054893:Cone-Beam Computed Tomography / Q000379:methods*; D006257:Head / Q000000981:diagnostic imaging; D006258:Head and Neck Neoplasms / Q000000981:diagnostic imaging* / Q000532:radiotherapy*; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods*; D009333:Neck / Q000000981:diagnostic imaging; D058958:Organs at Risk; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D061089:Radiotherapy, Image-Guided / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods; D012189:Retrospective Studies; D012867:Skin / Q000000981:diagnostic imaging; D012984:Software
keywords: adaptive radiation therapy; cone beam computed tomography; head and neck cancer