1

Variations in the Contouring of Target Structures and Organs at Risk: Test Case of a
Patient with Intermediate Risk Prostate Cancer
Brittany Bird, B.S., R.T.(R)(T), Veronica Laird-Abbott B.S., R.T.(T),
Bijoy Anand, M.S., Seth Cox, B.S., Stephanie Sanford, MSHA, R.T.(R)(T),
Pat Sheil, B.S., R.T.(T), Ashley Smelko B.S., R.T.(T), Sadie Wilhite, B.S., R.T.(R),
Nishele Lenards, M.S., CMD, R.T.(R)(T), FAAMD, Ashley Hunzeker, M.S., CMD,
Benjamin Nelms, Ph.D., Keitt Mobile, M.S., CMD, R.T.(R)(T), Kyle Burnett, M.S.,
Marc Posner, M.D.
ABSTRACT
The aim of this study was to evaluate the degree of inter-clinician variability in contouring
organs at risk (OR) and target volumes for external beam treatment of the prostate and seminal
vesicles using an analytical software provided by ProKnow Systems. The degree of variability
can determine the associated effects on the outcome of the treatment plan. A common dataset
with predefined targets from a patient with intermediate risk prostate cancer was provided to
multiple clinical facilities. A gold standard set of contours was provided by ProKnow to
compare results. A treatment plan was generated on the gold standard dataset according to
RTOG 0126 definitions. Qualified medical professionals were then asked to contour the
designated OR and create a clinical target volume (CTV) and planning target volume (PTV). The
23 datasets were anonymously sent back and the gold standard treatment plan was overlaid onto
all datasets. The plans were submitted to ProKnow for scoring accuracy. The dosimetric effects
due to contouring variability were quantified by comparing plans. Inter-clinician variation in OR
contouring of the male pelvis was significant in this study. Inter-clinician variability in
contouring needs to be further researched in order to improve treatment planning outcomes.
Treatment plans are often evaluated based on DVH results, however, contour variability can
produce a deceptive DVH results. Clinicians need to be aware of the over- and under-
contouring of structures and the effect on the final treatment plan results.

Key words: Contouring accuracy, Prostate cancer, Target volume, Organs at risk
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Introduction
A growth in technology has changed the spectrum of radiation oncology and has created
the ability to irradiate and target specific tumor volumes while sparing OR via contours drawn by
medical professionals. Volumetric-modulated arc therapy (VMAT) and intensity-modulated
radiation therapy (IMRT) are two specific techniques that allow for increased precision,
conformity, and achieve a steep dose gradient to spare nearby critical structures. The popularity
of these techniques compared to traditional 3D conformal radiotherapy has grown immensely. In
addition to treatment technique, anatomical contouring is an essential part of the treatment
planning process. If the structures are not clearly defined, the overall plan quality will be
affected. Contours create dose tracking not only to target volumes but also to OR; however,
incorrect contours or variances within contours can create inaccurate dose administration and
tracking. Deviations within contours may lead to over irradiation of normal tissue or cause
under-dosing to portions of the target volume.1
A select variety of contouring applications are available that allow the user to accurately
project the volume of an organ or delineate a target structure, interpolate between image slices,
define margins, and more. The tools inlaid in the contouring application allow the user to
perform the necessary tasks prior to beginning the treatment planning process. While contouring
is an important component, variations can inadvertently reflect a false depiction onto the dose-
volume histogram (DVH). There has been a lack of quality applications that can measure or
quantify the consistency and accuracy of contours, until most recently with the introduction of
ProKnow. ProKnow is one of the first analytic companies to develop a software program for
measuring contouring accuracy and radiation dose delivery. ProKnows software can aid in
identifying potential discrepancies in contouring, which in turn can help facilitate a reduction in
contouring inaccuracies throughout the radiation oncology community.
In 2010, Nelms et al3 studied the effects of target volume and OR contouring accuracy
and variability and the impact on treatment planning; identifying the necessity for awareness of
deviations in treatment planning evaluation.3 The study assessed contouring variability between
32 different clinicians on a common head and neck CT dataset from a patient with oropharyngeal
cancer. The study revealed significant differences in mean and maximum dose to the OR. The
authors stressed the importance of contouring, because the DVH is currently accepted as the
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primary tool for treatment plan evaluation by the radiation oncologist. The authors concluded
that target volume contouring was paramount, but OR should also be considered. 3
The primary objective of this study was to investigate the degree of inter-clinician
variability in target volume and OR contouring and the effects it has on treatment plan outcomes.
Subjective interpretation of OR and target volume delineation varies individually and this study
focused on the analysis and direct comparison of variations between structures utilizing the
metrics from the ProKnow StructSure software.
Methods and Materials
Patients
Selection criteria for this particular CT dataset included a patient who was diagnosed
with intermediate risk prostate cancer. The patients CT simulation was performed in a head-
first supine position utilizing a Philips wide bore CT scanner at a 3-mm slice thickness. A pillow
along with a large sponge was placed under the patients head to provide comfort and a knee-fix
was positioned under his knees to alleviate any back pressure. His feet were banded with a
rubber band for immobilization and his hands were located on his upper chest, out of the area of
interest. The bladder was moderate in size (75-85 cm3) and the rectum was not completely full
(78-88 cm3) for the scan. Temporary lateral reference marks were placed on the patients skin
during the simulation using the lap laser system.
Contouring
A digital imaging and communications in medicine (DICOM) dataset was initially
contoured by a radiation oncologist from ProKnow and served as the gold standard for
comparison. The dataset was also separately imported into each users contouring application.
A qualified medical professional (medical dosimetrist, medical physicist, or radiation oncologist)
from each facility then contoured the following five structures: bladder, penile bulb, prostate,
rectum, and seminal vesicles. Each user was instructed to create a CTV and a PTV. The CTV
was created to encompass the bilateral seminal vesicles in addition to the prostate, and the PTV
was created with a 5 mm uniform expansion from the CTV. The gold standard contours are
shown in Figure 1. The guidelines specified in the Radiation Therapy Oncology Group (RTOG)
0126 were utilized for contouring.4
Gold Standard Treatment Planning
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A treatment plan was generated using Pinnacle3 version 14.0 treatment planning system
(TPS) on the gold standard contour set. The prescription dose was set to 180 cGy per fraction for
39 fractions for a cumulative dose of 7020 cGy. An Elekta Agility linear accelerator equipped
with a 160 multi-leaf collimator was selected as the beam delivery device. The dose
computation method was the adaptive convolution algorithm. A total of two 10 MV VMAT
beams were chosen for this treatment plan given the depth of the target volume. Each beam
consisted of full arcs with the clockwise (CW) beam rotating from 179 to 181, and the counter-
clockwise (CCW) beam rotating from 180 to 178. A collimator angle of 5 was set on the CW
arc and a collimator angle of 355 was set on the CCW arc to avoid overlapping interleaf
transmission. The CW beam contributed 48.12% of the dose while the CCW contributed
51.88%. The dose grid was set to a 0.3 x 0.3 x 0.3 cm resolution for optimization.
The plan was produced by inverse planning and applying constraints from arm 1 of the
RTOG 0126 study.1 The calculated monitor units (MUs) for this plan had a total of 290.3 MU
per fraction. The global maximum dose was 7387 cGy, or 105% of the prescription dose. Figure
2 demonstrates the isodose distribution for this treatment plan.
Plan Comparisons
Several metrics were utilized for a comparison of each set of contours against the created
plan and optimized utilizing the gold standard contours. The items that were evaluated are listed
in Table 1. The dosimetric effects due to contouring differences were evaluated by replacing the
gold standard contours with each clinician's contours while keeping a fixed 3D dose grid.
Results
The results were quantified by a commercially available structure set analysis software
program called StructSure, supplied by ProKnow. A comparison of the RTOG 0126 volume
constraints versus the achieved results of the clinical reference plan is shown in Table 2. The
treatment plan met all dose constraints and objectives when submitted through the treatment
planning software.
Contouring
After receiving the contours of the five structures, the mean and standard deviations were
calculated from the gold standard reference plan and applied to the 23 datasets. Datasets were
collected from clinical internship facilities within the University of Wisconsin - La Crosse
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medical dosimetry program. From each site, either a medical dosimetrist, medical physicist, or a
radiation oncologist created the contours for the above structures.
For each of the 23 contoured datasets, a metric score of 116 points was produced and
developed with ProKnow. Each objective for the five contoured structures were weighted and
given a maximum number of points possible. The PTV was given a greater scoring objective due
to being the main volume receiving the prescription dose and its accuracy would affect the
outcome of a treatment plan. Points were assigned to the remaining organs with the penile bulb
receiving the fewest due to the small volume. Each dataset was given a score, based on the
requirements that were met with those contours. The PTV metric totaled 48 points, CTV totaled
12 points, rectum totaled 32 points, bladder totaled 20 points, and the penile bulb totaled 4
points. Points were awarded based on how well the metric was met.
The DVHs (Figure 3) display how the contoured volumes for the three different OR were
distributed. Of the 23 medical professionals, 19 under-contoured the rectum and 20 under-
contoured the penile bulb compared to the gold standard contour volumes. In contrast, the
bladder was over-contoured by 20 out of 23 study participants. The penile bulb had the highest
variation in volume, with a coefficient of 0.607. The penile bulb was the only structure whose
coefficient of volume variation was over 0.200. The bladder was found to have the lowest
variation in volume, with a coefficient of volume variation of 0.068. The CTV, PTV, and rectum
coefficient of volume variation all ranged between 0.100 and 0.200.
Treatment Planning
Contour variation also caused a variation in mean and maximum dose to the OR as well
as target volumes. The mean and maximum doses for each contoured structure are presented in
Table 4. Mean dose was more affected by contour discrepancies, as maximum dose for the
bladder was within 0.3% and maximum dose for the rectum was within 0.6%. However, mean
dose for each OR had a wider variance, with the average mean dose to the rectum varying by
3.6% greater than the gold standard mean dose and the bladder mean dose varying by 3.9%
greater than the gold standard mean dose.
The information analyzed from the study metrics and the 23 datasets obtained to
complete this study are shown in Table 3. Of particular interest was the PTV coverage and
maximum dose to the PTV as they accounted for the highest weighting in scoring (16 pts/each).
The volume (%) of the PTV covered by 70.2 Gy had two goals, 95% coverage was the minimum
 6

requirement and 100% was the ideal requirement. Out of the 23 datasets, 15 failed to meet the
minimum requirement and all 23 failed to meet the ideal requirement. The mean result among
all datasets was 94.30%. Volume (%) of the PTV covered by 75.1 Gy had two goals: 2% was the
minimum requirement and 0% was the ideal requirement. All 23 datasets passed the minimum
and ideal goal of this metric. The maximum dose (Gy) to the PTV had two goals: 77.2 Gy was
the maximum requirement of coverage needed and 75.1 Gy would be the ideal coverage of the
PTV contours. All 23 datasets passed the minimum and ideal goal for this metric as well. The
maximum possible metric score for all 13 sections combined was 116 pts. The total metric
scores for all 23 datasets were added and divided by the cumulative score to find the mean score.
The mean score amongst the entire data collected was 97.9/116 (84.4%).
Finally, a comparison of organ volume variation among all clinicians was analyzed.
Taken into consideration the 23 datasets utilized, the varied professionals did not show any
difference in contour volumes created. A total of 16 medical dosimetrists, 4 radiation
oncologists and 3 medical physicists contoured structure sets. The variance between each
profession is presented in Table 5. Medical dosimetrists had the lowest variance in mean rectal
dose within their contouring after the datasets were scored with the gold standard treatment plan
in ProKnow, with an average mean dose of 31.6 Gy, or a difference of 2.5%, while medical
physicists had the largest variance in mean dose of the rectum at 34.4 Gy or 11.6%. Contrarily,
radiation oncologists had the best mean dose once their contours were scored with the gold
standard treatment plan. The bladder at 49.2 Gy or 1.8% while the medical dosimetrists had the
greatest variance at 50.5 Gy or 4.5%. The maximum dose for each professional was within 0.5%
of the gold standard maximum dose for the rectum and within 0.4% of the gold standard
maximum dose for the bladder.
The mean dose to the penile bulb varied greatly among all of the professionals. Medical
dosimetrists remained closest within constraints of the mean dose at 23.33 Gy, or 76% higher
than the gold standard. However, medical physicists' structure sets received 42.52 Gy mean dose
delivered to the penile bulb, a 221% greater dose than the gold standard. While the mean dose is
still within the DVH criteria, it is a significant difference. However, PTV mean dose was close
for all professionals, calculated within 0.5% of the gold standard set.
Discussion
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To compare the inter-clinician contouring variability, a set of reference contours were

completed for the dataset on which a treatment plan was created to meet the required objectives.
For this study, the gold standard contours were the standard to compare against the clinicians'
contours. The goal of this study was to assess the degree of contour variations and the impact of
these variations. Any set of contours could have been used as the gold standard reference set of
contours, but there still would have been variability between each of the clinicians. It is most
important to note that contouring variability does exist and it does affect the DVH results.
This study revealed the variation of target volume and OR contouring over a population
of medical dosimetrists, medical physicists, and radiation oncologists for an intermediate risk
prostate cancer CT dataset. Historically there are many variations of inter-clinician contouring
of the male pelvis. In this study, the bladder proved to have the least variability. The increased
contouring accuracy of the bladder is expected due to its distinct boundaries that are often easily
identified on a CT scan.1 The rectum had the next lowest variability, following the bladder. The
superior portion of the rectum often has well defined borders. Moving inferiorly, the rectum is
commonly more difficult to identify as it reaches the prostate boundary and the anal canal.5
Finally, the penile bulb may only be seen on a few slices of the CT scan, making it difficult to
distinguish.
The variation of target volumes can play a considerable role in the evaluation of a
treatment plan. Variation in OR volume can drastically change the maximum dose to that
structure and also play a role in the increase or decrease of mean dose. Regarding contouring
OR, contouring accuracy is extremely important in dose tracking. If voxels are missing, the dose
to that area is not recorded. There is a potential for maximum dose to be missed for that
structure. For the OR, over-contouring is not as crucial, but it may produce an inaccurate mean
dose. If the extra voxels are contoured outside of the area of high-dose, then the mean dose will
be lower than it expected. The opposite affect would occur if the extra voxels were contoured
within the area of high dose.3 If the target structure is over-contoured, then the dose may
increase to the surrounding OR in order to achieve dose coverage of those extra voxels. If the
target structure is under-contoured, there may be disease outside of the treated area that is not
being adequately covered.
One consideration was a potential correlation between experience and training in terms of
mean and maximum doses. The greatest variance was for medical physicists given that their
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mean rectal dose results that were significantly higher. This could be attributed to the lack of
rectal contouring that medical physicists perform on a daily basis, but also could be due to very
small sample size of population within the study as only three respondents were medical
physicists. The overall results show there was no correlation between OR mean and maximum
dose and level of experience and training. Another significant point was that penile bulb
contouring had the largest variation. As shown in Perna et al,6 large variability in penile bulb
contouring could possibly result from inadequate access to MR fusion, the limitations of CT
imaging, and inexperience in the contouring of erectile structures.
Conclusion
Contouring deviations in target structures and OR is an ongoing conflict in radiation
oncology. Most treatment plans are evaluated by DVH results but DVH results can be deceptive
when overall contour volumes are inaccurate. Within this study, authors discovered that
variation in contours occurred at a high rate and varied greatly within medical dosimetrists,
medical physicists, and radiation oncologists.
Variations occurred in both over- and under-contouring, but the vast majority of volumes
significantly varied from the gold standard. These contour differences resulted in variances in
the overall dose being received to the contoured volumes. Of the contoured structures, the penile
bulb had the highest variation of volume with a coefficient of 0.607. The bladder had the lowest
variation of volume with a coefficient of 0.068. Out of the 23 data sets, 15 failed to meet the
ideal requirement of 95% volume coverage by 70.2 Gy. The mean score of all of the data
collected was a 97.9/116 (84.4%) according to the ProKnow metric scoring system.
A limitation of this study included the inability to overlay the 23 structure sets onto the
gold structure set. Since each structure set was individually graded against and on the gold
standard, there was an inability to format all 23 structure sets onto one final chart to see the
overall differentials that occurred in the contouring. The comparison of structure sets would
have given precise information representing over- and under- contouring. This limited the study
to be able to define the exact area of contour inaccuracy for target volumes and OR.
Future recommendations concluded from this study include finding the cause of the mean
dose discrepancy of contouring variations of OR within patients. Segmentation of the penile bulb
should be discussed and standardized throughout this profession, as each medical dosimetrist,
medical physicist, and radiation oncologist all had differing volumes and consequently, varying
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mean doses throughout. When contouring target volumes and OR, MR fusion can improve
variation in contouring and help with delineating soft tissue structures as is seen in the study by
Perna et al6 in contours of the penile bulb utilizing MR fusions.
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References
1. Collins KS. An evaluation of the contouring abilities of medical dosimetry students for
the anatomy of a prostate cancer patient. Med Dosim. 2012;37(3):245-249.
http://dx.doi.org/10.1016/j.meddos.2011.09.003
2. Bortfeld T, Jeraj R. The physical basis and future of radiation therapy. Br J Radiol.
2011;84(1002):485-498. http://dx.doi:10.1259/bjr/86221320
3. Nelms BE, Tom WA, Robinson G, Wheeler J. Variations in the contouring of organs at
risk: test case from a patient with oropharyngeal cancer. Int J Radiat Oncol Biol Phys.
2012;82(1):368-378. http://dx.doi.org/10.1016/j.ijrobp.2010.10.019
4. Michalski J, Moughan J, Purdy J, et al. Initial Results of a Phase III Randomized Study of
High Dose 3DCRT/IMRT versus Standard Dose 3D-CRT/IMRT in Patients Treated for
Localized Prostate Cancer (RTOG 0126). Int J of Radiat Oncol Biol Phys.
2014;90(5):1263. http://dx.doi.org/10.1016/j.ijrobp.2014.10.035
5. Barghi A, Johnson C, Warner A, et al. Impact of contouring variability on dose-volume
metrics used in treatment plan optimization of prostate IMRT. Cureus. 2013;5(11).
http://dx.doi.org/10.7759/cureus.144
6. Perna L, Cozzarini C, Maggiulli E, et al. Inter-observer variability in contouring the
penile bulb on CT images for prostate cancer treatment planning. Rad Onc. 2011;6:123.
http://dx.doi.org/10.1186/1748-717X-6-123
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Figures

Figure 1. Gold standard contours of the bladder (yellow), penile bulb (pink), rectum (green),
CTV (blue), and PTV (red).
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Figure 2. The isodose distribution using the gold contour treatment plan. The bladder is
contoured in yellow and rectum is contoured in green. The light green isodose line is the 100%
line, which encompasses the PTV (color washed red).
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Figure 3. DVHs of OR volumes defined for the same CT image set (defined by 23 contouring
clinicians per OR). The distribution of OR volume is a simple metric of variability.
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Tables
Table 1. Metrics for the treatment plan and contour evaluation.
Minimum
Metric Ideal Weight
Required
Volume (%) of the PTV covered by 70.2 (Gy) 95% 100% 16.00
Volume (%) of the PTV covered by 75.1 (Gy) 2% 0% 16.00
Maximum dose to the PTV 77.2 Gy 75.1 Gy 16.00
Volume (%) of the CTV covered by 70.2 (Gy) 95% 100% 12.00
Volume (cc) of the RECTUM covered by 75 (Gy) 15 cc 0 cc 8.00
Volume (%) of the RECTUM covered by 70 (Gy) 25% 5% 8.00
Volume (%) of the RECTUM covered by 65 (Gy) 35% 15% 8.00
Volume (%) of the RECTUM covered by 60 (Gy) 50% 25% 8.00
Volume (%) of the BLADDER covered by 80 (Gy) 15% 0% 8.00
Volume (%) of the BLADDER covered by 75 (Gy) 25% 5% 4.00
Volume (%) of the BLADDER covered by 70 (Gy) 35% 15% 4.00
Volume (%) of the BLADDER covered by 60 (Gy) 50% 25% 4.00
Mean dose to the PENILE BULB 52.5 Gy 20 Gy 4.00

TOTALS 13 Goals 13 Goals 116.00

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Table 2. Objectives for all the planning volumes and OR were met when comparing constraints
to the RTOG 0126 study.
Structure Dose Constraint Volume Constraint Achieved Goals Met?
PTV 110% (7720 cGy) 2% (minor variation) 0%
PTV 107% (7510 cGy) 2% 0%
PTV 100% (7020 cGy) 98% 98.05%
CTV 100% (7020 cGy) 100% 100%
Bladder 8000 cGy <15% 0%
Bladder 7500 cGy <25% 0%
Bladder 7000 cGy <35% 18.75%
Bladder 6500 cGy <50% 29.63%
Rectum 7500 cGy <15% 0%
Rectum 7000 cGy <25% 0.61%
Rectum 6500 cGy <35% 2.59%
Rectum 6000 cGy <50% 4.19%
Penile Bulb Mean Dose 5250 cGy 1314 cGy
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Table 3. Mean population results for the submitted datasets.

Weight
Minimum Mean Max Mean
Metric Ideal
Required Result Score Score
Volume (%) of the PTV
95% 100% 94.3 % 16.00 4.00
covered by 70.2 (Gy)
Volume (%) of the PTV
2% 0% 0% 16.00 16.00
covered by 75.1 (Gy)
Maximum dose to the PTV 77.2 Gy 75.1 Gy 73.87 Gy 16.00 16.00
Volume (%) of the CTV
95% 100% 99.75% 12.00 11.51
covered by 70.2 (Gy)
Volume of the RECTUM
15 cc 0 cc 0 cc 8.00 8.00
covered by 75 (Gy)
Volume (%) of the RECTUM
25 % 5% 0.38% 8.00 8.00
covered by 70 (Gy)
Volume (%) of the RECTUM
35% 15% 2.12% 8.00 8.00
covered by 65 (Gy)
Volume (%) of the RECTUM
50% 25% 3.86% 8.00 8.00
covered by 60 (Gy)
Volume (%) of the BLADDER
15% 0% 0% 8.00 8.00
covered by 80 (Gy)
Volume (%) of the BLADDER
25% 5% 0% 4.00 4.00
covered by 75 (Gy)
Volume (%) of the BLADDER
35% 15% 25.74% 4.00 1.98
covered by 70 (Gy)
Volume (%) of the BLADDER
50% 25% 42.39% 4.00 1.39
covered by 60 (Gy)
Mean dose to the PENILE
52.5 Gy 20 Gy 26.08 Gy 4.00 3.02
BULB

TOTALS 13 Goals 13 Goals 116.00 97.9

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Table 4. Average of all respondents vs the Gold Standard.

OR
Mean Dose Gold Standard Maximum Gold Standard
From all
Mean Dose Maximum
respondents
Bladder 50.2 Gy 48.32 Gy 73.51 Gy 73.27 Gy
Rectum 31.93 Gy 30.82 Gy 71.72 Gy 72.09 Gy
Penile Bulb 26.08 Gy 13.24 Gy 53.48 Gy 68.1 Gy
PTV 72.32 Gy 72.62 Gy NA NA
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Table 5. The variance in contouring between medical professional roles.

Radiation
Medical Medical Physicist Radiation
Physicist Oncologist
OR Dosimetrist Dosimetrist Mean Oncologist
Max Dose Mean
Mean Dose Max Dose Dose Max Dose
Dose
Bladder 50.5 Gy 73.41 Gy 50.2 Gy 73.56 Gy 49.2 Gy 73.44 Gy
Rectum 31.6 Gy 71.76 Gy 34.4 Gy 71.9 Gy 32.6 Gy 72.33 Gy
Penile Bulb 23.33 Gy 50 Gy 42.52 Gy 67.6 Gy 31.6 Gy 64.91 Gy
PTV 72.29 Gy NA 72.72 Gy NA 72.3 Gy NA