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Contrast Enhanced Oesophageal Avoidance for Stereotactic Body Radiotherapy: Barium vs. Gastrografin

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Contrast Enhanced Oesophageal Avoidance for Stereotactic Body Radiotherapy: Barium vs. Gastrografin

Katrina Woodford et al. Tech Innov Patient Support Radiat Oncol.

Abstract

Introduction: SABR may facilitate treatment in a greater proportion of locally-advanced NSCLC patients, just as it has for early-stage disease. The oesophagus is one of the key dose-limiting organs and visualization during IGRT would better ensure toxicity is avoided. As the oesophagus is poorly seen on CBCT, we assessed the extent to which this is improved using two oral contrast agents.

Materials & methods: Six patients receiving radiotherapy for Stage I-III NSCLC were assigned to receive 50 mL Gastrografin or 50 mL barium sulphate prior to simulation and pre-treatment CBCTs. Three additional patients who did not receive contrast were included as a control group. Oesophageal visibility was determined by assessing concordance between six experienced observers in contouring the organ. 36 datasets and 216 contours were analysed. A STAPLE contour was created and compared to each individual contour. Descriptive statistics were used and a Kappa statistic, Dice Coefficient and Hausdorff distance were calculated and compared using a t-test. Contrast-induced artefact was assessed by observer scoring.

Results: Both contrast agents significantly improved the consistency of oesophagus localisation on CBCT across all comparison metrics compared to CBCTs without contrast. Barium performed significantly better than Gastrografin with improved kappa statistics (p = 0.007), dice coefficients (p < 0.001) and Hausdorff distances (p = 0.002), although at a cost of increased image artefact.

Discussion: Barium produced lower delineation uncertainties but more image artefact, compared to Gastrografin and no contrast. It is feasible to use oral contrast as a tool in IGRT to help guide clinicians and therapists with online matching and monitoring of the oesophageal position.

Keywords: Cone-beam computed tomography; Oesophagus; Oral contrast; Stereotactic body radiotherapy.

Conflict of interest statement

The author declare that there is no conflict of interest.

Figures

Fig. 1
Fig. 1
Axial images of one patient’s (a) planning CT with Gastrografin, (b) CBCT with Gastrografin and (c) CBCT without contrast. Planning target volume in red. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Fig. 2
Fig. 2
Axial images of one patient after Gastrografin administration on different days showing inconsistent coating of the oesophagus – (a) poor coating and subsequently greater variation between observer contours compared to (b) improved coating, leading to less variation between contours.
Fig. 3
Fig. 3
Axial CBCT image showing artefact caused by barium in a dilated oesophagus.
Fig. 4
Fig. 4
Axial image of a pre-treatment contrast-enhanced CBCT on a patient where the contrast agent highlights the altered oesophagus position (blue) compared to the planned position (pink). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

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