Dosimetric impact of target definition in brachytherapy for cervical cancer – Computed tomography and trans rectal ultrasound versus magnetic resonance imaging

BACKGROUND AND PURPOSE: Magnetic Resonance Imaging (MRI) based target definition in cervix brachytherapy is limited by its availability, logistics and financial implications, therefore, use of computed tomography (CT) and Trans Rectal UltraSonography (TRUS) has been explored. The current study evaluated the dosimetric impact of CT + TRUS based target volumes as compared to gold standard MRI. METHODS AND MATERIALS: Images of patients (n = 21) who underwent TRUS followed by MRI and CT, were delineated with High-Risk Clinical Target Volume in CT (CTV(HR-CT)) and in MRI (CTV(HR-MR)). CTV(HR-CT) was drawn on CT images with TRUS assistance. For each patient, two treatment plans were made, on MRI and CT, followed by fusion and transfer of CTV(HR-MR) to the CT images, referred as CTV(HR-MRonCT). The agreement between CTV(HR-MRonCT) and CTV(HR-CT) was evaluated for dosimetric parameters (D(90), D(98) and D(50); Dose received by 90%, 98% and 50% of the volumes) using Bland-Altman plots, linear regression, and Pearson correlation. RESULTS: No statistically significant systematic difference was found between MRI and CT. Mean difference (±1.96 SD) of D(90), D(98) and D(50) between CTV(HR-MRonCT) and CTV(HR-CT) was 2.0, 1.2 and 5.6 Gy respectively. The number of patients who have met the dose constraints of D(90) > 85 Gy were 90% and 80% in MR and in CT respectively, others were in the borderline, with a minimum dose of 80 Gy. The mean ± SD dose-difference between MR and CT plans for bladder was significant (5 ± 13 Gy; p = 0.12) for D(0.1cm3), while others were statistically insignificant. CONCLUSION: CT + TRUS based delineation of CTV(HR) appear promising, provide useful information to optimally utilize for brachytherapy planning, however, MRI remains the gold standard.