Abstract. Image heterogeneity metrics such as textural features are an active area of research for evaluating clinical outcomes with positron emission tomography (PET) imaging and other modalities. However, the effects of stochastic image acquisition noise on these metrics are poorly understood. We performed a simulation study by generating 50 statistically independent PET images of the NEMA IQ phantom with realistic noise and resolution properties. Heterogeneity metrics based on gray-level intensity histograms, co-occurrence matrices, neighborhood difference matrices, and zone size matrices were evaluated within regions of interest surrounding the lesions. The impact of stochastic variability was evaluated with percent difference from the mean of the 50 realizations, coefficient of variation and estimated sample size for clinical trials. Additionally, sensitivity studies were performed to simulate the effects of patient size and image reconstruction method on the quantitative performance of these metrics. Complex trends in variability were revealed as a function of textural feature, lesion size, patient size, and reconstruction parameters. In conclusion, the sensitivity of PET textural features to normal stochastic image variation and imaging parameters can be large and is feature-dependent. Standards are needed to ensure that prospective studies that incorporate textural features are properly designed to measure true effects that may impact clinical outcomes.

Purpose Patient‐specific quality assurance (QA) for intensity‐modulated radiation therapy (IMRT) is a ubiquitous clinical procedure, but conventional methods have often been criticized as being insensitive to errors or less effective than other common physics checks. Recently, there has been interest in the application of radiomics, quantitative extraction of image features, to radiotherapy QA. In this work, we investigate a deep learning approach to classify the presence or absence of introduced radiotherapy treatment delivery errors from patient‐specific QA. Methods Planar dose maps from 186 IMRT beams from 23 IMRT plans were evaluated. Each plan was transferred to a cylindrical phantom CT geometry. Three sets of planar doses were exported from each plan corresponding to (a) the error‐free case, (b) a random multileaf collimator (MLC) error case, and (c) a systematic MLC error case. Each plan was delivered to the electronic portal imaging device (EPID), and planned and measured doses were used to calculate gamma images in an EPID dosimetry software package (for a total of 558 gamma images). Two radiomic approaches were used. In the first, a convolutional neural network with triplet learning was used to extract image features from the gamma images. In the second, a handcrafted approach using texture features was used. The resulting metrics from both approaches were input into four machine learning classifiers (support vector machines, multilayer perceptrons, decision trees, and k‐nearest‐neighbors) in order to determine whether images contained the introduced errors. Two experiments were considered: the two‐class experiment classified images as error‐free or containing any MLC error, and the three‐class experiment classified images as error‐free, containing a random MLC error, or containing a systematic MLC error. Additionally, threshold‐based passing criteria were calculated for comparison. Results In total, 303 gamma images were used for model training and 255 images were used for model testing. The highest classification accuracy was achieved with the deep learning approach, with a maximum accuracy of 77.3% in the two‐class experiment and 64.3% in the three‐class experiment. The performance of the handcrafted approach with texture features was lower, with a maximum accuracy of 66.3% in the two‐class experiment and 53.7% in the three‐class experiment. Variability between the results of the four machine learning classifiers was lower for the deep learning approach vs the texture feature approach. Both radiomic approaches were superior to threshold‐based passing criteria. Conclusions Deep learning with convolutional neural networks can be used to classify the presence or absence of introduced radiotherapy treatment delivery errors from patient‐specific gamma images. The performance of the deep learning network was superior to a handcrafted approach with texture features, and both radiomic approaches were better than threshold‐based passing criteria. The results suggest that radiomic QA is a promising direction f...

a b s t r a c tBackground: Treatment decisions for multimodal therapy in soft tissue sarcoma (STS) patients greatly depend on the differentiation between low-grade and high-grade tumors. We developed MRI-based radiomics grading models for the differentiation between low-grade (G1) and high-grade (G2/G3) STS. Methods: The study was registered at ClinicalTrials.gov (number NCT03798795). Contrast-enhanced T1-weighted fat saturated (T1FSGd), fat-saturated T2-weighted (T2FS) MRI sequences, and tumor grading following the French Federation of Cancer Centers Sarcoma Group obtained from pre-therapeutic biopsies were gathered from two independent retrospective patient cohorts. Volumes of interest were manually segmented. After preprocessing, 1394 radiomics features were extracted from each sequence. Features unstable in 21 independent multiple-segmentations were excluded. Least absolute shrinkage and selection operator models were developed using nested cross-validation on a training patient cohort (122 patients). The influence of ComBatHarmonization was assessed for correction of batch effects. Findings: Three radiomic models based on T2FS, T1FSGd and a combined model achieved predictive performances with an area under the receiver operator characteristic curve (AUC) of 0.78, 0.69, and 0.76 on the independent validation set (103 patients), respectively. The T2FS-based model showed the best reproducibility. The radiomics model involving T1FSGd-based features achieved significant patient stratification. Combining the T2FS radiomic model into a nomogram with clinical staging improved prognostic performance and the clinical net benefit above clinical staging alone. Interpretation: MRI-based radiomics tumor grading models effectively classify low-grade and high-grade soft tissue sarcomas.

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Pretreatment physics plan review is a key safety measure and can detect a high percentage of errors. However, the majority of errors that potentially could have been detected were not detected in this study, indicating the need to improve the pretreatment physics plan review performance. Suggestions for improvement include the automation of specific physics checks performed during the pretreatment physics plan review and the standardization of the review process.

The increasing interest in combined positron emission tomography (PET) and computed tomography (CT) to guide lung cancer radiation therapy planning has been well documented. Motion management strategies during treatment simulation PET/CT imaging and treatment delivery have been proposed to improve the precision and accuracy of radiotherapy. In light of these research advances, why has translation of motion‐managed PET/CT to clinical radiotherapy been slow and infrequent? Solutions to this problem are as complex as they are numerous, driven by large inter‐patient variability in tumor motion trajectories across a highly heterogeneous population. Such variation dictates a comprehensive and patient‐specific incorporation of motion management strategies into PET/CT‐guided radiotherapy rather than a one‐size‐fits‐all tactic. This review summarizes challenges and opportunities for clinical translation of advances in PET/CT‐guided radiotherapy, as well as in respiratory motion‐managed radiotherapy of lung cancer. These two concepts are then integrated into proposed patient‐specific workflows that span classification schemes, PET/CT image formation, treatment planning, and adaptive image‐guided radiotherapy delivery techniques.

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