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This study was conducted to evaluate the variability of gross tumor volume (GTV) using  11 C-Choline and  18 F-FDG PET/CT images for nasopharyngeal carcinomas boundary definition. Assessment consisted of inter-observer and inter-modality variation analysis. Four radiation oncologists were invited to manually contour GTV by using PET/CT fusion obtained from a cohort of 12 patients with nasopharyngeal carcinoma (NPC) and who underwent both  11 C-Choline and  18 F-FDG scans. Student’s paired-sample  t -test was performed for analyzing inter-observer and inter-modality variability. Semi-automatic segmentation methods, including thresholding and region growing, were also validated against the manual contouring of the two types of PET images. We observed no significant variation in the results obtained by different oncologists in terms of the same type of PET/CT volumes. Choline fusion volumes were significantly larger than the FDG volumes (p < 0.0001, mean ± SD = 18.21 ± 8.19). While significantly consistent results were obtained between the oncologists and the standard references in Choline volumes compared with those in FDG volumes (p = 0.0025). Simple semi-automatic delineation methods indicated that  11 C-Choline PET images could provide better results than FDG volumes (p = 0.076, CI = [–0.29, 0.025]).  11 C-Choline PET/CT may be more advantageous in GTV delineation for the radiotherapy of NPC than  18 F-FDG. Phantom simulations and clinical trials should be conducted to prove the possible improvement of the treatment outcome.

Variability of Gross Tumor Volume in Nasopharyngeal Carcinoma Using 11C-Choline and 18F-FDG PET/CT