Evaluating the Hounsfield unit assignment and dose differences between CT‐based standard and deep learning‐based synthetic CT images for MRI‐only radiation therapy of the head and neck
Authors: Singhrao Kamal , Dugan Catherine Lu , Calvin Christina , Pelayo Luis , Yom Sue Sun , Chan Jason Wing‐Hong , Scholey Jessica Elizabeth , Singer Lisa 
Published: December 2023

AbstractBackgroundMagnetic resonance image only (MRI‐only) simulation for head and neck (H&N) radiotherapy (RT) could allow for single‐image modality planning with excellent soft tissue contrast. In the MRI‐only simulation workflow, synthetic computed tomography (sCT) is generated from MRI to provide electron density information for dose calculation. Bone/air regions produce little MRI signal which could lead to electron density misclassification in sCT. Establishing the dosimetric impact of this error could inform quality assurance (QA) procedures using MRI‐only RT planning or compensatory methods for accurate dosimetric calculation.PurposeThe aim of this study was to investigate if Hounsfield unit (HU) voxel misassignments from sCT images result in dosimetric errors in clinical treatment plans.MethodsFourteen H&N cancer patients undergoing same‐day CT and 3T MRI simulation were retrospectively identified. MRI was deformed to the CT using multimodal deformable image registration. sCTs were generated from T1w DIXON MRIs using a commercially available deep learning‐based generator (MRIplanner, Spectronic Medical AB, Helsingborg, Sweden). Tissue voxel assignment was quantified by creating a CT‐derived HU threshold contour. CT/sCT HU differences for anatomical/target contours and tissue classification regions including air (<250 HU), adipose tissue (–250 HU to –51 HU), soft tissue (–50 HU to 199 HU), spongy (200 HU to 499 HU) and cortical bone (>500 HU) were quantified. t‐test was used to determine if sCT/CT HU differences were significant. The frequency of structures that had a HU difference > 80 HU (the CT window‐width setting for intra‐cranial structures) was computed to establish structure classification accuracy. Clinical intensity modulated radiation therapy (IMRT) treatment plans created on CT were retrospectively recalculated on sCT images and compared using the gamma metric.ResultsThe mean ratio of sCT HUs relative to CT for air, adipose tissue, soft tissue, spongy and cortical bone were 1.7 ± 0.3, 1.1 ± 0.1, 1.0 ± 0.1, 0.9 ± 0.1 and 0.8 ± 0.1 (value of 1 indicates perfect agreement). T‐tests (significance set at t = 0.05) identified differences in HU values for air, spongy and cortical bone in sCT images compared to CT. The structures with sCT/CT HU differences > 80 HU of note were the left and right (L/R) cochlea and mandible (>79% of the tested cohort), the oral cavity (for 57% of the tested cohort), the epiglottis (for 43% of the tested cohort) and the L/R TM joints (occurring > 29% of the cohort). In the case of the cochlea and TM joints, these structures contain dense bone/air interfaces. In the case of the oral cavity and mandible, these structures suffer the additional challenge of being positionally altered in CT versus MRI simulation (due to a non‐MR safe immobilizing bite block requiring absence of bite block in MR). Finally, the epiglottis HU assignment suffers from its small size and unstable positionality. Plans recalculated on sCT yielded global/local gamma pass rates of 95.5% ± 2% (3 mm, 3%) and 92.7% ± 2.1% (2 mm, 2%). The largest mean differences in D95, Dmean, D50 dose volume histogram (DVH) metrics for organ‐at‐risk (OAR) and planning tumor volumes (PTVs) were 2.3% ± 3.0% and 0.7% ± 1.9% respectively.ConclusionsIn this cohort, HU differences of CT and sCT were observed but did not translate into a reduction in gamma pass rates or differences in average PTV/OAR dose metrics greater than 3%. For sites such as the H&N where there are many tissue interfaces we did not observe large scale dose deviations but further studies using larger retrospective cohorts are merited to establish the variation in sCT dosimetric accuracy which could help to inform QA limits on clinical sCT usage.