# Construction of Prediction Model of Radiotherapy Set-Up Errors in Patients with Lung Cancer

Authors: Fan Yang; Xinxia Li
Journal: BioMed Research International
 (2022)

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## Abstract

Objective. This study intends to construct an error distribution prediction model and analyze its parameters and analyzes the boundary size of CTV extension to PTV, so as to provide a reference for lung cancer patients to control clinical set-up errors and radiotherapy planning. Methods. The prior SBRT set-up error data of 50 patients with lung cancer treated by medical linear accelerator were selected, the Gaussian mixture model was adopted to construct the error distribution prediction model, and the model parameters were solved, based on which the emission boundary from CTV to PTV was calculated. Results. According to the analysis of the model parameters, the spatial distribution of set-up errors is mainly concentrated in the direction of four central points (μ1 ~ μ4), and the error is smaller in the Vrt direction (-0.991~2.808 mm) and Lat direction (-0.447~1.337 mm) and larger in the Lng direction (-1.065~4,463 mm). The possibility of offset of set-up errors in μ2 and μ3 direction (0.4440, 02198) is greater than that of μ1 and μ4 (0.1767, 0.1595). The standard deviation of set-up errors can reach 0.538 mm. The theoretical expansion boundary of CTV to PTV in Vrt, Lng, and Lat can be calculated as 1.7963 mm, 2.3749 mm, and 0.6066 mm. Conclusion. The GMM Gaussian mixture model can quantitatively describe and predict the set-up errors distribution of lung cancer patients and can obtain the emission boundary of CTV to PTV, which provides a reference for radiotherapy set-up errors control and tumor planning target expansion of lung cancer patients without SBRT.


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## Body

## 1. Introduction

With the development of tumor radiotherapy technology in recent years, stereotactic body radiation therapy (SBRT) has gradually become the standard treatment method for inoperable patients with early non-small-cell lung cancer (NSCLC) because of its advantages of less damage, less treatment times, and promoting the reoxidation of tumor hypoxic cells [1]. As SBRT is more adopted in tumor radiotherapy, the positioning accuracy of radiotherapy has higher requirements. In order to achieve accurate radiotherapy, the key is to keep the height of the patient’s posture consistent with that of positioning. In addition, in order to ensure the accuracy of radiotherapy, the postural uncertainty of patients during radiotherapy must be taken into account. When sketching and planning the target volume, it can be achieved by expanding a certain distance on the clinical target volume (CTV) to form a planning target volume (PTV), which includes organ movement and set-up errors [2]. In this study, 550 groups of set-up error data of 50 patients with lung cancer during the treatment period were collected, observed, and statistically analyzed, and the emission boundary of CTV-PTV was obtained, which provides the data basis for clinical practice.


## 2. Materials and Methods

### 2.1. Case Selection

50 patients with lung cancer were treated with medical linear accelerator (Elekta Infinity), and SBRT was performed in the department of radiotherapy of Zhejiang People’s Hospital from January 2020 to July 2021. The clinical data and SBRT set-up error data of each treatment were obtained by cone-beam computed tomography (CBCT) with medical linear accelerator (Elekta Infinity). Among the 50 patients with lung cancer, 36 were male, and 14 were female. The age distribution of the patients was 28-86 years old. According to the choice of chest plain scan in patients with lung cancer, conical beam CT scan was performed once a week. After scanning, CT image registration was performed and the data of lung cancer patients in three directions: vertical direction (Vrt), longitudinal direction (Lng), and lateral direction (Lat) were recorded. A total of 550 times SBRT error data were collected to build the model, and all treatments were carried out on the Elekta accelerator. After the scanning was completed, the CT image data were transmitted to the Monaco treatment planning system workstation through DICOM, the target volume was sketched by the doctor, and the plan was designed by the physicist.


### 2.2. Construction of Prediction Model of Set-up Error Distribution in Radiotherapy for Patients with Lung Cancer

For the collected data samples, many uncertain factors in the actual recording process were taken into account. It is necessary to screen the data, filter out the “noise” samples, and retain the real set-up error data before building a distribution prediction model for the data samples. As a consequence, based on the 3σ principle, this study excludes the data points that do not meet this rule and constructs the set-up error distribution prediction model for the screened data. The main purpose of this study is to build a prediction model of set-up error distribution. When getting data samples, there is no real sample label to calibrate; that is, this is an unsupervised learning data set. This study uses the common unsupervised learning algorithm: Gaussian mixture clustering (GMM) to cluster the untagged data and label each data point to get the overall distribution of the data [3]. In the process of GMM, because we do not know the label of the data points, it is impossible to evaluate the clustering results. Usually, the clustering results are evaluated based on the principle of maximum intercluster distance and minimum intracluster distance. Contour coefficient is the most commonly adopted evaluation index of this kind of clustering. This study is also based on the index of contour coefficient to evaluate the result of GMM clustering.


## 2.1. Case Selection

50 patients with lung cancer were treated with medical linear accelerator (Elekta Infinity), and SBRT was performed in the department of radiotherapy of Zhejiang People’s Hospital from January 2020 to July 2021. The clinical data and SBRT set-up error data of each treatment were obtained by cone-beam computed tomography (CBCT) with medical linear accelerator (Elekta Infinity). Among the 50 patients with lung cancer, 36 were male, and 14 were female. The age distribution of the patients was 28-86 years old. According to the choice of chest plain scan in patients with lung cancer, conical beam CT scan was performed once a week. After scanning, CT image registration was performed and the data of lung cancer patients in three directions: vertical direction (Vrt), longitudinal direction (Lng), and lateral direction (Lat) were recorded. A total of 550 times SBRT error data were collected to build the model, and all treatments were carried out on the Elekta accelerator. After the scanning was completed, the CT image data were transmitted to the Monaco treatment planning system workstation through DICOM, the target volume was sketched by the doctor, and the plan was designed by the physicist.


## 2.2. Construction of Prediction Model of Set-up Error Distribution in Radiotherapy for Patients with Lung Cancer

For the collected data samples, many uncertain factors in the actual recording process were taken into account. It is necessary to screen the data, filter out the “noise” samples, and retain the real set-up error data before building a distribution prediction model for the data samples. As a consequence, based on the 3σ principle, this study excludes the data points that do not meet this rule and constructs the set-up error distribution prediction model for the screened data. The main purpose of this study is to build a prediction model of set-up error distribution. When getting data samples, there is no real sample label to calibrate; that is, this is an unsupervised learning data set. This study uses the common unsupervised learning algorithm: Gaussian mixture clustering (GMM) to cluster the untagged data and label each data point to get the overall distribution of the data [3]. In the process of GMM, because we do not know the label of the data points, it is impossible to evaluate the clustering results. Usually, the clustering results are evaluated based on the principle of maximum intercluster distance and minimum intracluster distance. Contour coefficient is the most commonly adopted evaluation index of this kind of clustering. This study is also based on the index of contour coefficient to evaluate the result of GMM clustering.


## 3. The Concrete Process of the Prediction Model of Set-Up Error Distribution

### 3.1. Data Preprocessing

Considering the authenticity of the data samples, the data were screened based on the 3σ principle. First of all, the center of the data point of the sample was calculated. For the data in three directions, the Vrt direction and Lng were larger, and Lat could reflect the three coordinates of the data point in the three-dimensional space. We calculated the cosine distance between each data point and the center point, got the distance data of each data point, fitted the distance data, and got the result of Gaussian distribution (Figure 1). When the data point was more than 3σ, the data point shown in Figure 2 was finally obtained. The sphere was a boundary with the center point as the sphere center and 3σ as the radius. In Figure 2, the X axis was lateral, the Y axis was longitudinal, and the Z axis was vertical.Figure 1
Gaussian fitting result of the distance from the data point to the center point.Figure 2
Data distribution after data preprocessing.


### 3.2. Optimal Clustering Number Based on Contour Coefficient Index

Contour coefficient is the evaluation index of the most commonly adopted clustering algorithm [4]. It is defined for each different sample, and the profile coefficient of a single sample is calculated as follows:
(1)s=b−amaxa,b.It can be expressed as follows:(2)s=1−baifa<b0,ifa=bba−1ifa>bWe could find out the best cluster number by setting different cluster numbers and giving the corresponding contour coefficient values. In this study, the clustering number was set to an integer within [2, 5], and the data points were clustered by GMM. Finally, the change of the value of the profile factor was obtained, and the result was shown in Figure 3.Figure 3
Change diagram of contour coefficient value.When the clustering numberk was set to 4, the value of the contour coefficient reached the maximum, and the curve of the contour coefficient reached the inflection point (Figure 3). As a consequence, it is most suitable for the data set that the clustering number k is 4 from this index.


### 3.3. GMM Model for Predicting the Distribution of Set-up Errors

From a mathematical point of view, any continuous nonlinear function can be superimposed by several Gaussian distribution functions and approach the function infinitely. Gaussian mixture clustering is a clustering method based on this principle, which belongs to unsupervised learning algorithm in machine learning. The GMM model uses Gaussian probability density function to quantify things accurately and decomposes a thing into several journeys based on Gaussian probability density function. Theoretically, no matter what the distribution law of the observed data set is, the real distribution can be infinitely approximated by the GMM model [6]. The distribution of this data can be expressed as follows:
(3)Pyθ=∑k=1kαkΦyθk,whereαk represents the weight coefficient of each Gaussian distribution, the sum of which is 1; φ (y|Θk) is the Gaussian distribution density; Θk=μk,σ2k, and the Gaussian distribution density is as follows:
(4)θyθk=12σ2πe−y−μk22σk2.That is, it represents thek-th Gaussian distribution density function.In general, because the GMM model function is difficult to deal with through expansion to find the partial derivative, and the optimization problem is troublesome, so the EM algorithm is usually adopted to solve its parameters. The EM algorithm is an expectation maximization algorithm. In statistics, it is often adopted to find the maximum likelihood estimation of parameters of probability models that depend on unobservable hidden variables. It is an effective method to solve the optimization problem of hidden variables [4].


## 3.1. Data Preprocessing

Considering the authenticity of the data samples, the data were screened based on the 3σ principle. First of all, the center of the data point of the sample was calculated. For the data in three directions, the Vrt direction and Lng were larger, and Lat could reflect the three coordinates of the data point in the three-dimensional space. We calculated the cosine distance between each data point and the center point, got the distance data of each data point, fitted the distance data, and got the result of Gaussian distribution (Figure 1). When the data point was more than 3σ, the data point shown in Figure 2 was finally obtained. The sphere was a boundary with the center point as the sphere center and 3σ as the radius. In Figure 2, the X axis was lateral, the Y axis was longitudinal, and the Z axis was vertical.Figure 1
Gaussian fitting result of the distance from the data point to the center point.Figure 2
Data distribution after data preprocessing.


## 3.2. Optimal Clustering Number Based on Contour Coefficient Index

Contour coefficient is the evaluation index of the most commonly adopted clustering algorithm [4]. It is defined for each different sample, and the profile coefficient of a single sample is calculated as follows:
(1)s=b−amaxa,b.It can be expressed as follows:(2)s=1−baifa<b0,ifa=bba−1ifa>bWe could find out the best cluster number by setting different cluster numbers and giving the corresponding contour coefficient values. In this study, the clustering number was set to an integer within [2, 5], and the data points were clustered by GMM. Finally, the change of the value of the profile factor was obtained, and the result was shown in Figure 3.Figure 3
Change diagram of contour coefficient value.When the clustering numberk was set to 4, the value of the contour coefficient reached the maximum, and the curve of the contour coefficient reached the inflection point (Figure 3). As a consequence, it is most suitable for the data set that the clustering number k is 4 from this index.


## 3.3. GMM Model for Predicting the Distribution of Set-up Errors

From a mathematical point of view, any continuous nonlinear function can be superimposed by several Gaussian distribution functions and approach the function infinitely. Gaussian mixture clustering is a clustering method based on this principle, which belongs to unsupervised learning algorithm in machine learning. The GMM model uses Gaussian probability density function to quantify things accurately and decomposes a thing into several journeys based on Gaussian probability density function. Theoretically, no matter what the distribution law of the observed data set is, the real distribution can be infinitely approximated by the GMM model [6]. The distribution of this data can be expressed as follows:
(3)Pyθ=∑k=1kαkΦyθk,whereαk represents the weight coefficient of each Gaussian distribution, the sum of which is 1; φ (y|Θk) is the Gaussian distribution density; Θk=μk,σ2k, and the Gaussian distribution density is as follows:
(4)θyθk=12σ2πe−y−μk22σk2.That is, it represents thek-th Gaussian distribution density function.In general, because the GMM model function is difficult to deal with through expansion to find the partial derivative, and the optimization problem is troublesome, so the EM algorithm is usually adopted to solve its parameters. The EM algorithm is an expectation maximization algorithm. In statistics, it is often adopted to find the maximum likelihood estimation of parameters of probability models that depend on unobservable hidden variables. It is an effective method to solve the optimization problem of hidden variables [4].


## 4. Results

As a consequence, we can pass the cluster number and cluster center point determined by the contour coefficient method to the GMM model, use the EM algorithm for iterative calculation, and finally get the three parameters of the GMM model, so as to build a prediction model about the set-up error distribution. The clustering effect is shown in Figure4.Figure 4
Clustering effect of GMM.The parameters of the GMM error distribution prediction model are as follows: the coordinates of each error center (that is, the meanμ of the GMM model) is shown in Table 1; the covariance matrix of the error model (i.e. the GMM model σ) is shown in Table 2; the probability of each error center (that is, the coefficient α of the GMM model) is shown in Table 3.Table 1
Center point coordinates of set-up errors.
CenterVrt/mmLng/mmLat/mmμ1-0.991-1.125-0.771μ20.1174.463-0.590μ32.808-3.122-0.447μ40.5311.0651.337Table 2
Center point probability of set-up errors.
Centerμ1μ2μ3μ4Probability0.17670.44400.21980.1595Table 3
Covariance of the GMM model.
μ10.5660.0635-0.136-0.006350.1990.020-0.1360.0200.377μ20.211-0.017-0.029-0.0170.526-0.00493-0.029-0.004930.122μ30.538-0.023-0.056-0.0230.095-0.0797-0.056-0.07970.055μ40.3620.1450.0310.1450.3360.0300.0310.0300.608The distribution characteristics of the set-up errors can be obtained from the data in the table, which is mainly concentrated in the direction of four central points (μ1 ~ μ4). The coordinate values of each center point can reflect the average offset direction and offset of the point in the center. From the overall distribution, all the positions are smaller in the Vrt direction offset (-0.991~2.808 mm) and Lat direction offset (-0.447~1.337 mm) but larger in the Lng direction (-1.065~4,463 mm). The probability of the set-up errors center (coefficient α) reflects the possibility that the error distribution falls in and near the center [6]. From the probability of each center, the possibility of set-up errors offset in the direction of μ2 and μ3 (0.4440, 02198) is greater than that of μ1 and μ4 (0.1767, 0.1595). The covariance matrix (coefficient σ) of the model reflects the statistical standard deviation, which can reach 0.538 mm.


## 5. Emission Boundary of CTV to PTV

According to the formulaMPTV=2.5∑Total+0.7σtotal proposed by Herk et al., ∑ is the standard deviation, and σ is the root mean square of the standard deviation. M is the boundary value of PTV obtained by CTV expansion based on the above calculation [7, 8].The theoretical expansion boundaries of Vrt, Lng, and Lat can be calculated as shown in Table 4.Table 4
Set-up errors and emission boundary of patients with lung cancer.
Coordinate directionCasesSet-up times∑σEmission boundaryVrt505500.10721.841.7963Lng505500.05228.822.3749Lat50550-0.21616.380.6066


## 6. Discussion

How to improve the positioning accuracy of radiotherapy and effectively reduce the set-up errors is the most concerned issue in clinic with the development of radiotherapy technology. When the set-up errors are large, it will lead to insufficient dose in the target volume and too much X-ray exposure to the normal tissue. With the application of CBCT technology, the set-up errors of patients before treatment can be corrected. However, the dose of X-rays produced by CBCT tends to increase the probability of secondary tumors [8, 9]. If we can accurately predict the set-up errors of patients during each treatment, we can reduce the set-up errors of patients and minimize the frequency of using CBCT.The results of Van’s research show that the set-up errors during treatment includes three axial direction errors between and within radiotherapy [10]. On the basis of this theory, the Gaussian mixture model is adopted to construct the error distribution prediction model by collecting the SBRT set-up error data set of 50 patients with lung cancer. After analyzing the parameters, the error distribution law is obtained, and the set-up error probability is predicted. The set-up errors are not only a simple error in three axial directions but also tends to be concentrated in several definite central directions in the space. By calculating the coordinates and probabilities of several central points, the possible offset direction and distribution probability of each central point can be obtained.In addition, the determination of PTV emission boundary is a key issue in tumor radiotherapy [5, 11]. A reasonable PTV boundary should not only ensure the possible movement volume including the target volume but also reduce the organ tolerance of normal tissue near the target volume as much as possible. As a consequence, the set-up errors are an important factor in determining the extension distance from CTV to PTV [12]. The research results of this study show that the emission boundary of PTV should not only be considered from the three axes of Vrt, Lng, and Lat but also should be expanded comprehensively in the direction and variance of its four offset centers. It is necessary to carry out nonuniform expansion in each center offset direction and include the variance offset [6].The set-up error prediction model constructed in this study needs to be further improved. It can only predict the overall set-up error distribution of patients but cannot accurately predict the set-up errors of patients during each treatment [13, 14]. In addition, all patients are fixed in supine posture. The set-up errors of patients with other fixed positions have not been predicted by this model. In addition, only 50 cases were collected for statistical analysis, and more clinical data can be collected in the future.



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