Transrectal ultrasound for image-guided adaptive brachytherapy in cervix cancer - An alternative to MRI for target definition?

PURPOSE

To compare the maximum high risk clinical target volume (CTV) dimensions and image quality between magnetic resonance imaging (MRI), transrectal ultrasound (TRUS) and computed tomography (CT) in image guided adaptive brachytherapy (IGABT) of locally advanced cervical cancer.

MATERIAL AND METHODS

All patients with locally advanced cervical cancer treated with radiochemotherapy and IGABT between 09/2012-05/2013 were included in this study. T2-weighted MRI (1.5 tesla), TRUS and CT were performed before (MRI, TRUS) and/or after (MRI, TRUS and CT) insertion of the applicator. 3D TRUS image acquisition was done with a customized US stepper device and software. The HR CTV was defined on 3D image sequences acquired with different imaging modalities by one blinded observer, in accordance to the GEC-ESTRO recommendations for MRI-based target volume delineation, as the complete cervical mass including the tumour, any suspicious areas of parametrial involvement and the normal cervical stroma. Maximum HR CTV width and thickness were measured on transversal planes. Image quality was classified using the following scoring system: Grade 0: not depicted, Grade 1: inability to discriminate, margin not recognizable, Grade 2: fair discrimination, margin indistinct, Grade 3: excellent discrimination, margin distinct. Descriptive statistics, mean differences between the groups, with MRI as reference, and a paired t-test were calculated.

RESULTS

Images from 19 patients (FIGO IB: 3, IIB: 9, IIIB: 5, IVB: 2) were available for analysis. The mean difference in maximum HR CTV width of TRUS TRUS MRI CT to MRI was 0.0mm±4.7 (n.s.), -1.1mm±5.6 (n.s.), 0.7mm±6.4 (n.s.) and 13.8mm±6.7 (p<0.001). The mean difference in maximum HR CTV thickness of TRUS TRUS MRI CT to MRI was -3.4mm±5.9 (p=0.037), -3.4mm±4.2 (p<0.001), 2.0mm±6.1 (n.s.) and 13.9mm±6.3 (p<0.001). Mean scores of image quality of the target volume was 2.9 for TRUS, 2.3 for TRUS, 2.9 for MRI, 2.7 for MRI and 2.1 for CT.

CONCLUSION

For the assessment of the HR CTV in IGABT of cervical cancer, TRUS is within the intraobserver variability of MRI. TRUS is superior to CT as it yields systematically smaller deviations from MRI, with good to excellent image quality. Small differences of TRUS HR CTV thickness are likely related to differences in image slice orientation and compression of the cervix by the TRUS probe before insertion of the brachytherapy applicator.