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Weissmann T, Mansoorian S, May MS, Lettmaier S, Höfler D, Deloch L, Speer S, Balk M, Frey B, Gaipl US, Bert C, Distel LV, Walter F, Belka C, Semrau S, Iro H, Fietkau R, Huang Y, Putz F. Deep Learning and Registration-Based Mapping for Analyzing the Distribution of Nodal Metastases in Head and Neck Cancer Cohorts: Informing Optimal Radiotherapy Target Volume Design. Cancers (Basel) 2023; 15:4620. [PMID: 37760588 PMCID: PMC10526893 DOI: 10.3390/cancers15184620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
We introduce a deep-learning- and a registration-based method for automatically analyzing the spatial distribution of nodal metastases (LNs) in head and neck (H/N) cancer cohorts to inform radiotherapy (RT) target volume design. The two methods are evaluated in a cohort of 193 H/N patients/planning CTs with a total of 449 LNs. In the deep learning method, a previously developed nnU-Net 3D/2D ensemble model is used to autosegment 20 H/N levels, with each LN subsequently being algorithmically assigned to the closest-level autosegmentation. In the nonrigid-registration-based mapping method, LNs are mapped into a calculated template CT representing the cohort-average patient anatomy, and kernel density estimation is employed to estimate the underlying average 3D-LN probability distribution allowing for analysis and visualization without prespecified level definitions. Multireader assessment by three radio-oncologists with majority voting was used to evaluate the deep learning method and obtain the ground-truth distribution. For the mapping technique, the proportion of LNs predicted by the 3D probability distribution for each level was calculated and compared to the deep learning and ground-truth distributions. As determined by a multireader review with majority voting, the deep learning method correctly categorized all 449 LNs to their respective levels. Level 2 showed the highest LN involvement (59.0%). The level involvement predicted by the mapping technique was consistent with the ground-truth distribution (p for difference 0.915). Application of the proposed methods to multicenter cohorts with selected H/N tumor subtypes for informing optimal RT target volume design is promising.
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Affiliation(s)
- Thomas Weissmann
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
- Bavarian Cancer Research Center (BZKF), 81377 Munich, Germany; (S.M.); (F.W.); (C.B.)
| | - Sina Mansoorian
- Bavarian Cancer Research Center (BZKF), 81377 Munich, Germany; (S.M.); (F.W.); (C.B.)
- Department of Radiation Oncology, University Hospital, Ludwig Maximilian University of Munich, 81377 Munich, Germany
| | - Matthias Stefan May
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
- Department of Radiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
| | - Daniel Höfler
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
| | - Lisa Deloch
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
- Translational Radiobiology, Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Stefan Speer
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
| | - Matthias Balk
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
- Department of Otolaryngology, Head and Neck Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
- Translational Radiobiology, Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Udo S. Gaipl
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
- Translational Radiobiology, Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
| | - Luitpold Valentin Distel
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
| | - Franziska Walter
- Bavarian Cancer Research Center (BZKF), 81377 Munich, Germany; (S.M.); (F.W.); (C.B.)
- Department of Radiation Oncology, University Hospital, Ludwig Maximilian University of Munich, 81377 Munich, Germany
| | - Claus Belka
- Bavarian Cancer Research Center (BZKF), 81377 Munich, Germany; (S.M.); (F.W.); (C.B.)
- Department of Radiation Oncology, University Hospital, Ludwig Maximilian University of Munich, 81377 Munich, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
| | - Heinrich Iro
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
- Department of Otolaryngology, Head and Neck Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
- Bavarian Cancer Research Center (BZKF), 81377 Munich, Germany; (S.M.); (F.W.); (C.B.)
| | - Yixing Huang
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
| | - Florian Putz
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (T.W.); (S.L.); (D.H.); (L.D.); (S.S.); (B.F.); (U.S.G.); (C.B.); (L.V.D.); (S.S.); (R.F.)
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany; (M.S.M.); (M.B.); (H.I.)
- Bavarian Cancer Research Center (BZKF), 81377 Munich, Germany; (S.M.); (F.W.); (C.B.)
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Vogel MME, Düsberg M, Stöhrer L, Dewes S, Sage EK, Borm KJ, Gschwend JE, Eiber M, Combs SE, Schiller K. Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography-based Lymph Node Atlas for Salvage Radiotherapy in Patients with Recurrent Prostate Cancer: A Validation of the New NRG Oncology 2020 guideline. Eur Urol Oncol 2022; 5:668-676. [PMID: 36280446 DOI: 10.1016/j.euo.2022.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/07/2022] [Accepted: 09/30/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Approximately 20-40% of patients with prostate cancer (PC) who undergo radical prostatectomy (RP) experience relapse, with the majority of these cases developing pelvic lymph node (LN) metastases. Taking new data from the prostate-specific membrane antigen (PSMA) positron emission tomography (PET) era into account, the Radiation Therapy Oncology Group (RTOG) 2009 contouring guideline for the pelvic LNs from 2009 was updated by the NRG Oncology group in 2020 (NRG 2020). OBJECTIVE To evaluate and validate the updated NRG 2020 guideline with our established LN atlas. DESIGN, SETTING, AND PARTICIPANTS We screened 1653 PSMA PET/computed tomography (CT) data sets for patients with biochemical relapse who underwent a PET scan between November 2012 and November 2017. After screening, we developed an LN atlas using data from 233 patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We evaluated LN overlap (OL) with the RTOG 2009 and NRG 2020 contouring guidelines. OL was defined as within (>90%), partly within (10-90%), or outside (<10%). RESULTS AND LIMITATIONS In comparison to the RTOG 2009 guideline, 403 (52%), 134 (17%), and 241 (31%) of the LNs were not, were partly, or were fully covered within the overall group, respectively. By contrast, using the NRG 2020 guideline, 302 (39%), 190 (24%), and 286 (37%) of the LNs were not, were partly, or were fully covered, respectively (p < 0.001). Limitations include the retrospective design with missing data and no histopathological confirmation of the PET results. CONCLUSIONS The updated NRG 2020 contouring guideline improves coverage of the pelvic LNs in patients undergoing salvage radiation therapy. However, PET/CT should be considered whenever possible to ensure coverage of untypical LN spread. PATIENT SUMMARY We compared the 2009 and 2020 guidelines on the radiation area for the pelvis for patients with recurrent prostate cancer that has spread to lymph nodes. The newer guideline provides better coverage of pelvic lymph nodes than the older one and is useful in planning radiation therapy. However, a scan of the pelvis using the newest technique should be considered for individual patients to ensure coverage of untypical lymph nodes.
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Affiliation(s)
- Marco M E Vogel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany.
| | - Mathias Düsberg
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Lucia Stöhrer
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Sabrina Dewes
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Eva K Sage
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Kai J Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Jürgen E Gschwend
- Department of Urology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Matthias Eiber
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany; Institute for Radiation Medicine, Department of Radiation Sciences, Helmholtz Zentrum München, Neuherberg, Germany; Deutsches Konsortium für Translationale Krebsforschung, Munich Partner Site, Munich, Germany
| | - Kilian Schiller
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
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