Comparison of four synthetic CT generators for brain and prostate MR-only workflow in radiotherapy.

Background: The interest in MR-only workflows is growing with the introduction of artificial intelligence in the synthetic CT generators converting MR images into CT images. The aim of this study was to evaluate several commercially available sCT generators for two anatomical localizations.

Methods: Four sCT generators were evaluated: one based on the bulk density method and three based on deep learning methods. The comparison was performed on large patient cohorts (brain: 42 patients and pelvis: 52 patients). It included geometric accuracy with the evaluation of Hounsfield Units (HU) mean error (ME) for several structures like the body, bones and soft tissues. Dose evaluation included metrics like the D ME for bone structures (skull or femoral heads), PTV and soft tissues (brain or bladder or rectum). A 1%/1 mm gamma analysis was also performed.

Results: HU ME in the body were similar to those reported in the literature. D ME were smaller than 2% for all structures. Mean gamma pass rate down to 78% were observed for the bulk density method in the brain. Performances of the bulk density generator were generally worse than the artificial intelligence generators for the brain but similar for the pelvis. None of the generators performed best in all the metrics studied.

Conclusions: All four generators can be used in clinical practice to implement a MR-only workflow but the bulk density method clearly performed worst in the brain.