Dosimetric uncertainties of three-dimensional dose reconstruction from two-dimensional data in a multi-institutional study

Abstract

Inconsistencies in the treatment planning process leading to dosimetric uncertainties may affect conclusions drawn from interinstitutional radiation oncology clinical trials. The purpose of this study was to assess the dosimetric uncertainties resulting from the process of reconstructing three-dimensional dose distributions from two-dimensional treatment plan information provided by participating institutions in a randomized clinical trial. This study was based on American College of Radiology Protocol #427, Locally Advanced Multi-Modality Protocol; a multi-institutional phase II randomized study involving radiation therapy for patients with inoperable non-small cell lung cancer. Several sources of dosimetric uncertainty were identified and analyzed, including image quality of hard-copy computed tomography (CT) images, slice spacing of CT scans, treatment position, interpretations of target volumes by radiation oncologists, the contouring of normal anatomic structures, and the use of common beam models for all dose calculations. Each source of uncertainty was investigated using a set of plans, with the ideal characteristics of digital images with 3-mm axial slice spacing and a flat couch, consisting of eight cases from Vanderbilt University Medical Center with electronically transferred CT data. The target volume DVH values were dependent on the additional uncertainty introduced by differences in delineation of the target volumes by the participating radiation oncologists. The DVH values for the lungs and heart were dependent on image quality and treatment position. Esophagus DVH values were not dependent on any of the sources of uncertainty. None of the structure DVH values were dependent on slice thickness or variations in the contouring of normal anatomic structures. In designing a cooperative protocol, to ensure that dosimetric inaccuracies are minimized, care must be taken to include reliable means of transmitting high-quality CT data and to ensure consistency in the delineation of tumor volumes.