Abstract

The use of stereotactic radiosurgery (SRS) employing one or a few fractions of high doses of radiation has continuously increased due to the technical development in dose delivery and morphological and functional imaging. As the target volume in SRS is usually defined without margins, the treatment success critically depends on accurate definition and contouring of the target volume and organs at risk (OARs) which are commonly situated in the proximity of the target making their precise delineation particularly important in order to limit possible normal tissue complications. Subsequent treatment planning is reliant on these volumes, which makes the accurate contouring a requisite to high quality treatments.
The purpose of this work was to evaluate the current degree of variability for target and OAR contouring and to establish methods for analysing multiobserver data regarding structure delineation variability. Furthermore, this was set in a broader picture including the importance of contouring studies, the clinical implications of contouring errors and the possible mitigation of the variability in contouring by robust treatment planning.
A multi-centre target and OAR contouring study was initiated. Four complex and six common cases to be treated with SRS were selected and subsequently distributed to centres around the world performing Gamma Knife® radiosurgery for delineation and treatment planning. The resulting treatment plans and the corresponding delineated structures were collected and analysed.
Results showed a very high variability in contouring for the four complex radiosurgery targets. Similar results indicating high variability in delineating the common targets and OARs were also reported. This emphasised the need of continuous work towards consistent and standardized SRS treatments. Consequently, the results of the OAR analysis were incorporated in an effort to standardize stereotactic radiosurgery (SRS). Variations in treatment planning were as well analysed for several of the indications included in the initial study on contour delineation and the results showed a high variability in planned doses including several plans presenting large volumes of the brain receiving a higher dose than 12 Gy, indicating an elevated risk of normal tissue complications.
The results of the contouring work were, as a last step of this thesis, used as input for a robust treatment planning approach considering the variability in target delineation. The very preliminary results indicate the feasibility of the probabilistic approach and the potential of robust treatment planning to account for uncertainties in target extent and location.