Megavoltage computed tomography image guidance with helical tomotherapy in patients with vertebral tumors: analysis of factors influencing interobserver variability.

Purpose: To evaluate megavoltage computed tomography (MVCT)-based image guidance with helical tomotherapy in patients with vertebral tumors by analyzing factors influencing interobserver variability, considered as quality criterion of image guidance.

Methods And Materials: Five radiation oncologists retrospectively registered 103 MVCTs in 10 patients to planning kilovoltage CTs by rigid transformations in 4 df. Interobserver variabilities were quantified using the standard deviations (SDs) of the distributions of the correction vector components about the observers' fraction mean. To assess intraobserver variabilities, registrations were repeated after ≥4 weeks. Residual deviations after setup correction due to uncorrectable rotational errors and elastic deformations were determined at 3 craniocaudal target positions. To differentiate observer-related variations in minimizing these residual deviations across the 3-dimensional MVCT from image resolution effects, 2-dimensional registrations were performed in 30 single transverse and sagittal MVCT slices. Axial and longitudinal MVCT image resolutions were quantified. For comparison, image resolution of kilovoltage cone-beam CTs (CBCTs) and interobserver variability in registrations of 43 CBCTs were determined.

Results: Axial MVCT image resolution is 3.9 lp/cm. Longitudinal MVCT resolution amounts to 6.3 mm, assessed as full-width at half-maximum of thin objects in MVCTs with finest pitch. Longitudinal CBCT resolution is better (full-width at half-maximum, 2.5 mm for CBCTs with 1-mm slices). In MVCT registrations, interobserver variability in the craniocaudal direction (SD 1.23 mm) is significantly larger than in the lateral and ventrodorsal directions (SD 0.84 and 0.91 mm, respectively) and significantly larger compared with CBCT alignments (SD 1.04 mm). Intraobserver variabilities are significantly smaller than corresponding interobserver variabilities (variance ratio [VR] 1.8-3.1). Compared with 3-dimensional registrations, 2-dimensional registrations have significantly smaller interobserver variability in the lateral and ventrodorsal directions (VR 3.8 and 2.8, respectively) but not in the craniocaudal direction (VR 0.75).

Conclusion: Tomotherapy image guidance precision is affected by image resolution and residual deviations after setup correction. Eliminating the effect of residual deviations yields small interobserver variabilities with submillimeter precision in the axial plane. In contrast, interobserver variability in the craniocaudal direction is dominated by the poorer longitudinal MVCT image resolution. Residual deviations after image guidance exist and need to be considered when dose gradients ultimately achievable with image guided radiation therapy techniques are analyzed.