Clinical implementation of dual-energy CT for proton treatment planning on pseudo-monoenergetic CT scans

Purpose: To determine whether a standardized clinical application of dual-energy CT (DECT) for proton treatment planning based on pseudo-monoenergetic CT scans (MonoCT) is feasible and leads to more reliable proton range predictions as compared to single-energy CT (SECT).

Methods and Materials: To define an optimized DECT protocol, CT scan settings were analyzed experimentally concerning beam hardening, image quality and influence on the heuristic conversion of CT numbers into stopping-power ratios (SPRs) using phantoms consisting of tissue surrogates and compared to SECT scans with identical CT dose. Differences in range prediction and dose distribution between SECT and MonoCT were quantified for phantoms and patients.

Results: Dose distributions planned on SECT and MonoCT datasets revealed mean range deviations of 0.3 mm, gamma passing rates (1%, 1 mm) greater than 99.9% and no clinically relevant changes in dose-volume histograms. However, image noise and CT-related uncertainties could be reduced by MonoCT compared to SECT with identical CT dose, which might result in a more reliable proton range prediction. Consequently, DECT was clinically implemented at the University Proton Therapy Dresden. 120 planning and 499 control DECT scans of overall 144 patients were acquired from April 2015 until May 2016.

Conclusions: A standardized clinical use of MonoCT for proton treatment planning is feasible, leads to improved image quality, extends diagnostic variety and enables a stepwise clinical implementation of DECT towards a physics-based, patient-specific, non-heuristic SPR determination. Further reductions of CT-related uncertainties, as expected from such SPR approaches, can be evaluated on the resulting DECT patient database.