Interobserver variability in target volume delineation for CT/MRI simulation and MRI- guided adaptive radiotherapy in rectal cancer

Objectives: Quantify target volume delineation uncertainty for CT/MRI simulation and MRIguided adaptive radiotherapy in rectal cancer. Define optimal imaging sequences for target delineation. Methods: Six experienced radiation oncologists delineated clinical target volumes (CTVs) on CT and 2D and 3D- MRI in three patients with rectal cancer, using consensus contouring guidelines. Tumour GTV (GTVp) was also contoured on MRI acquired week 0 and 3 of radiotherapy. A STAPLE contour was created and volume and interobserver variability metrics were analysed. Results: There were statistically significant differences in volume between observers for CT and 2D- MRIdefined CTVs (p < 0.05). There was no significant difference between observers on 3D- MRI. Significant differences in volume were seen between observers for both 2D and 3D- MRI-defined GTVp at weeks 0 and 3 (p < 0.05). Good interobserver agreement (IOA) was seen for CTVs delineated on all imaging modalities with best IOA on 3D- MRI; median Conformity index (CI) 0.74 for CT, 0.75 for 2D- MRI and 0.77 for 3D- MRI. IOA of MRIdefined GTVp week 0 was better compared to CT; CI 0.58 for CT, 0.62 for 2D- MRI and 0.7 for 3D- MRI. MRIdefined GTVp IOA week three was worse compared to week 0. Conclusion: Delineation on MRI results in smaller volumes and better IOA week 0 compared to CT. 3D- MRI provides the best IOA in CTV and GTVp. MRIdefined GTVp on images acquired week 3 showed worse IOA compared to week 0. This highlights the need for consensus guidelines in GTVp delineation on MRI during treatment course in the context of dose escalation MRIguided rectal boost studies. Advances in knowledge: Optimal MRI sequences for CT/MRI simulation and MRIguided adaptive radiotherapy in rectal cancer have been defined.