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A combination of descriptive statistics, overlap measure, and statistical measure of agreement or reliability analysis is required to fully report the interrater variability in delineation.

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OBJECTIVE Treatment of parasagittal meningiomas is still considered a challenge in modern microsurgery. The use of microsurgical resection, radiosurgery, or a microsurgery-radiosurgery combination treatment strategy is often debated. The aim of this study was to evaluate the treatment of parasagittal meningioma and provide evidence that a multimodal approach reduces complication rates and achieves good tumor control rates. METHODS The authors retrospectively reviewed long-term follow-up data on 117 patients who had been treated for parasagittal meningiomas at their institution between 1993 and 2013. Treatment included microsurgery, Gamma Knife radiosurgery (GKRS), and radiotherapy. RESULTS The median tumor volume prior to the first microsurgical resection was largest in the microsurgery-radiosurgery combination treatment group. Invasion of the superior sagittal sinus was significantly associated with a Simpson Grade IV resection and subsequent radiosurgery treatment. The Simpson resection grade did not influence time to progression or recurrence in benign meningioma cases. Complete sinus occlusion was followed by microsurgical resection of the occluded sinus, by tumor resection without resection of the sinus, or by GKRS. Histopathology revealed WHO Grade I tumors in most patients. However, a high percentage (33%) of atypical or malignant meningiomas were diagnosed after the last microsurgical resection. The time to recurrence or progression after microsurgery was significantly longer in patients with WHO Grade I meningiomas than in those with Grade II or III meningiomas. At follow-up, tumor control rates after GKRS were 91% for presumed meningioma, 85% for benign meningioma, 71% for atypical meningioma, and 38% for malignant meningioma. CONCLUSIONS A multimodal treatment approach to parasagittal meningiomas reduces the rate of complications. Thus, microsurgery, radiotherapy, and radiosurgery are complementary treatment options. Gamma Knife radiosurgery is safe and effective in patients with meningiomas invading the superior sagittal sinus. The procedure can be part of a multimodal treatment plan or administered as a single treatment in well-selected patients.

We present an evaluation of various non-rigid registration algorithms for the purpose of compensating interfractional motion of the target volume and organs at risk areas when acquiring CBCT image data prior to irradiation. Three different deformable registration (DR) methods were used: the Demons algorithm implemented in the iPlan Software (BrainLAB AG, Feldkirchen, Germany) and two custom-developed piecewise methods using either a Normalized Correlation or a Mutual Information metric (featureletNC and featureletMI). These methods were tested on data acquired using a novel purpose-built phantom for deformable registration and clinical CT/CBCT data of prostate and lung cancer patients. The Dice similarity coefficient (DSC) between manually drawn contours and the contours generated by a derived deformation field of the structures in question was compared to the result obtained with rigid registration (RR). For the phantom, the piecewise methods were slightly superior, the featureletNC for the intramodality and the featureletMI for the intermodality registrations. For the prostate cases in less than 50% of the images studied the DSC was improved over RR. Deformable registration methods improved the outcome over a rigid registration for lung cases and in the phantom study, but not in a significant way for the prostate study. A significantly superior deformation method could not be identified.

Patients undergoing radiotherapy will inevitably show anatomical changes during the course of treatment. These can be weight loss, tumour shrinkage, and organ motion or filling changes. For advanced and adaptive radiotherapy (ART) information about anatomical changes must be extracted from repeated images in order to be able to evaluate and manage these changes. Deformable image registration (DIR) is a tool that can be used to efficiently gather information about anatomical changes. The aim of the present study was to evaluate the performance of two DIR methods for automatic organ at risk (OAR) contour propagation. Datasets from ten gynaecological patients having repeated computed tomography (CT) and cone beam computed tomography (CBCT) scans were collected. Contours were delineated on the planning CT and on every repeated scan by an expert clinician. DIR using our in-house developed featurelet-based method and the iPlan® BrainLab treatment planning system software was performed with the planning CT as reference and a selection of repeated scans as the target dataset. The planning CT contours were deformed using the resulting deformation fields and compared to the manually defined contours. Dice's similarity coefficients (DSCs) were calculated for each fractional patient scan structure, comparing the volume overlap using DIR with that using rigid registration only. No significant improvement in volume overlap was found after DIR as compared with rigid registration, independent of which image modality or DIR method was used. DIR needs to be further improved in order to facilitate contour propagation in the pelvic region in ART approaches.

PTV2 has a high impact on the treated volume and on sparing of organs at risk. The combination of an adaptive target volume definition with protons could contribute to future PHL treatment concepts.