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Purpose  We have developed a multi-modal imaging approach for SIRT, combining  99m Tc-MAA SPECT/CT and/or  90 Y PET,  18 F-FDG PET/CT, and contrast-enhanced CBCT for voxel-based dosimetry, as a tool for treatment planning and verification. For radiation dose prediction calculations, a segmentation of the total liver volume and of the liver perfusion territories is required.    Method  In this paper, we proposed a procedure for multi-modal image analysis to assist SIRT treatment planning. The pre-treatment  18 F-FDG PET/CT,  99m Tc-MAA SPECT/CT, and contrast-enhanced CBCT images were registered to a common space using an initial rigid, followed by a deformable registration. The registration was scored by an expert using Likert scores. The total liver was segmented semi-automatically based on the PET/CT and SPECT/CT images, and the liver perfusion territories were determined based on the CBCT images. The segmentations of the liver and liver lobes were compared to the manual segmentations by an expert on a CT image.    Result  Our methodology showed that multi-modal image analysis can be used for determination of the liver and perfusion territories using CBCT in SIRT using all pre-treatment studies. The results for image registration showed acceptable alignment with limited impact on dosimetry.  The image registration performs well according to the expert reviewer (scored as perfect or with little misalignment in 94% of the cases). The semi-automatic liver segmentation agreed well with manual liver segmentation (dice coefficient of 0.92 and an average Hausdorff distance of 3.04 mm). The results showed disagreement between lobe segmentation using CBCT images compared to lobe segmentation based on CT images (average Hausdorff distance of 14.18 mm), with a high impact on the dosimetry (differences up to 9 Gy for right and 21 Gy for the left liver lobe).    Conclusion  This methodology can be used for pre-treatment dosimetry and for SIRT planning including the determination of the activity that should be administered to achieve the therapeutical goal. The inclusion of perfusion CBCT enables perfusion-based definition of the liver lobes, which was shown to be markedly different from the anatomical definition in some of the patients.

Multi-modal image analysis for semi-automatic segmentation of the total liver and liver arterial perfusion territories for radioembolization