1

Dose Differences Due to Variance in Contours of the Optic Chiasm

Authors: Bradley Newby, R.T.(T), Aaron Ayers BS, R.T.(R)(T), Hoi Wai Chau MS, Nishele
Lenards PhD, CMD, R.T.(R)(T), FAAMD, Ashley Hunzeker MS, CMD, Mathew Tobler R.T.
(T), CMD, FAAMD.
Medical Dosimetry Program at the University of Wisconsin - La Crosse
Abstract
Previous researchers have shown a high degree of variability in optic chiasm contours but
have not investigated the implications of this variability. The hypothesis that this variability led
to greater dose to the anatomical optic chiasm compared to the contoured chiasm was tested.
Sixteen participant contours were generated by medical dosimetrists and physicians, and 1 expert
radiation oncologist contour was gathered and noted as the anatomical optic chiasm. The
participant and expert contours were used in the re-optimization of an existing test plan. Data
regarding dose to the participant contour and expert contour, as well as planning target volume
(PTV) and gross tumor volume (GTV) coverage was gathered. In 75% of cases, the median,
mean, maximum, and minimum doses were higher for the expert contour than for the participant
contour and the range of dose was roughly three times greater as well. The mean dose to the
expert contour was 44cGy higher than the mean dose to the participant contour. These data
indicate that, in 75% of cases, the anatomical optic chiasm received a dose that was higher than
the plan would have indicated based on the inaccurately drawn optic chiasm. This is important as
it may result in the optic chiasm receiving a dose exceeding limit while an inaccurate optic
chiasm contour displays a tolerance within constraint.
Keywords: optic chiasm, contouring, radiation therapy, intensity modulated radiation therapy,
brain
Introduction
The introduction of intensity modulated radiation therapy (IMRT), stereotactic
radiosurgery (SRS), stereotactic body radiation therapy (SBRT), as well as associated
advancements in technology, has led to more precise treatments in radiation therapy. More
precise treatment equates to radiation being more accurately shaped to targets, reducing the dose
to adjacent organs at risk (OAR) and increasing dose to the target.1 The process of dose
escalation has many potential benefits. Higher, ablative dose to tumors results in greater local
control and increased potential for the abscopal effect.2 However, dose escalation is highly
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reliant upon precise application of dose. Any mistakes, inaccuracies, or improperly shaped dose
can result in unintentional high doses to adjacent OAR.2 These unintentional high doses are of
particular importance in areas such as the head and neck and brain, where many radiosensitive
OAR are clustered in tight proximity.
One radiosensitive structure in the brain is the optic chiasm. The optic chiasm is an X
shaped nerve bundle created by the overlap of the optic nerves.3 The optic chiasm is a small
structure, measuring 3.5 x 15.0 mm on average, and often difficult or impossible to visualize on
CT imaging.4 Magnetic resonance imaging (MRI) is more commonly used to visualize the optic
chiasm, but the structure may still be difficult to discern depending on the quality of the MRI and
the size of the organ. Vogin et al5 reported that the optic chiasm is one of the most variably
contoured OAR in the cranium, with an interrater reliability kappa index of just 0.3 compared to
0.8 for the brainstem and parotid glands.5 According to McHugh,6 the kappa index score
indicates minimal agreement, with only 4.0 – 15.0% of the data being reliable. Clayton et al7
found similar results, with only 26% agreement on CT contours and 40% on MRI. Wright et al8
further noted a lack of standardization of optic chiasm contours between facilities and
individuals, with few following the recommendations of established contouring atlases.
Variability of contours presents a critical dosimetric issue. When contours do not reflect
accurate delineation of organs, medical dosimetrists cannot ensure accurate dose calculation and
distribution during treatment planning. The contouring inaccuracies may result in unintentional
overdose to radiosensitive OAR or underdose to targets. Loo et al9 observed variation in parotid
gland contours in IMRT cases and reported significant differences in dose as a result of different
contours. Four oncologists and 3 radiologists were asked to delineate the parotid gland on an
existing radiation therapy plan. The overall dose to the new volumes was evaluated against the
overall dose to the original volumes. The original volumes all received doses within 10% of 24
Gy (24 Gy +/-2.4 Gy), but only 54% of the new volumes received doses within the same range.
The 46% of volumes receiving doses outside of the 10% variation range were deemed
sufficiently different and likely to have resulted in a different IMRT plan if they were used.9
Nelms et al10 asked several clinics to contour and create an IMRT plan based on a single patient
dataset which resulted in 32 usable plans that were compared for inter-clinic variation in OAR
contours and dose. Dose differences arising solely from contour variation ranged from - 289% to
+ 56% for mean OAR dose and - 22% to + 35% for maximum dose.10 The fact that these
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contours varied so greatly demonstrated the potential inaccuracies and variability of dose to
delineated OAR.10 As Martel et al11 and Chi et al12 reported, surpassing constraints on the optic
nerves and chiasm can easily lead to long term side effects, including moderate to severe vision
loss. It is therefore of utmost importance that delineated anatomical contours accurately reflect
the organs at risk.
As dose escalation continues to increase, it is increasingly important that radiosensitive
structures be adequately protected. The problem is that contours of the optic chiasm vary
between institutions and individuals, which can result in different doses to the anatomical
structure. While other researchers have examined the variability in dose due to variations in
contours for other OAR, the potential dose variations for the optic chiasm are unknown. The
purpose of this study was to determine the dose variance caused by differing optic chiasm
contours compared to published contouring guidelines. Researchers tested the hypotheses that
(H1A) there is a statistically significant variation (> 5% Sørensen–Dice coefficient) between the
optic chiasm contours of participants and published contouring guidelines, and that (H2A) the
variation in contouring of the optic chiasm results in higher doses to the correctly contoured
optic chiasm compared to the incorrectly contoured optic chiasm.
Materials and Methods
Test Data
A test image dataset and plan were used for this study to eliminate any ambiguity through
use of multiple patient files. The test plan was selected from a former patient treatment plan
generated with IMRT and with the planning target volume (PTV) abutment to the optic chiasm.
These inclusion criteria provided the ideal scenario for variability in contours and differences in
dose. The test plan had a PTV prescription dose of 180 cGy for 33 fractions for a total of 5940
cGy to at least 95% of the PTV. The optic chiasm constraint was a maximum point of 5500 cGy.
A 2 mm margin was placed around the optics (optic chiasm and both optic nerves) and used as
an optimization structure to reduce optic chiasm dose.
To test the variability of optic chiasm contours and the associated variations in dose, a set
of optic chiasm contours were required. In addition, an expert contour which accurately
represented the anatomical chiasm was also required. To prepare the test dataset for participant
contouring, the existing contours and plan were removed from the test dataset, resulting in an
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empty CT/MRI image dataset. The dataset was anonymized and submitted to the participants for
contouring.
Contouring
The Varian Eclipse contouring system and the MIM software were used for contouring.
All participants were presented with the same test dataset. Both the CT and MRI were available
for the participants to examine, though neither were given preference. The participants were
asked to contour the optic chiasm, with no further information given about its proportions,
location, and extent, etc. No limit was placed on the amount of time the participants could take,
nor on the contouring tools to be used. Participants were not allowed to use any external tools or
references such as contouring atlases, advice or aid from other individuals, or the previous
contours created by other participants. Thus, contours were based only on prior knowledge and
understanding of the optic chiasm. After each participant completed contouring, no additional
edits were permitted. The completed participant contours were given an anonymous numerical
designation and stored for later use. In addition to these contours, the single expert contour was
generated by a radiation oncologist utilizing contouring guidelines set by Wright et al.8 This
expert contour served as the baseline for accuracy. Sixteen participant contours and a single
expert contour were collected. All contours were collated onto a single master dataset and then
transferred back to the original, retrospective test dataset.
Treatment Planning
The test dataset, with the 16 participant contours and 1 expert contour, was imported into
the Eclipse treatment planning system (TPS). The radiation therapy plan within the test dataset
was then duplicated 17 times: once for each participant optic chiasm contour, and a final time for
the expert contour. Each copied plan was then assigned a single participant contour as well as the
expert contour. The participant contour was used for optimization, while the expert contour was
used for dose comparison and was not used in optimization. The final, 17th plan was optimized
using the expert optic chiasm contour for comparison purposes. For each plan, a 2.0 mm optics
margin was created around the participant contour. No other structures were changed.
After a duplicate plan was created for each contour, plans were optimized using the
optimization criteria utilized for the original, retrospective test plan. Parameters such as Non-
Target Optimization (NTO) and grid size were not changed. The optimizer was allowed to
calculate a full optimization cycle and was paused for 60 seconds after intermediate dose
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calculation to allow the plan to restabilize, then allowed to complete the optimization process.
After a single full optimization, the optimizer was initiated once more, but only through the
fourth step, to provide the system an opportunity for further fine tuning. This allowed the
optimizer to create a new plan based on the participant optic chiasm contour. The plan was then
calculated for final dose evaluation.
Expert Baseline Dose
For the expert contour plan, the maximum point dose to the chiasm was 5527.1 cGy, the
mean dose was 5361 cGy, the percentage of the PTV covered by prescription dose was 58.7%,
and the percentage of the GTV covered by prescription dose was 56.6%. The minimum PTV
dose was 5364 cGy, and the minimum GTV dose was 5501.6 cGy.
Statistical Analyses
Several comparisons between contours and doses were completed. The first comparison
was variability of contours. Utilizing MIM, each participant contour was compared against the
expert contour, with the emphasis on differences in volumes enclosed. A Sørensen–Dice
Coefficient (Dice Score) was generated through this comparison, which was used as an objective
measure of difference from the expert contour. In addition, the participant contours were
compared against the other participant contours to generate Dice Scores of intra-contour
agreement.
Dose data was recorded for each participant contour as well as the expert contour for
each plan including the maximum dose, the volume of chiasm contour receiving greater than the
chiasm constraint dose of 55 Gy, and the difference in maximum dose between the participant
contour and the expert contour. In addition, dose data were recorded for both the PTV and Gross
Tumor Volume (GTV) which included: percentage of volume receiving at least 100% of the
prescription dose and absolute minimum dose within the PTV/GTV contour. The purpose of this
data collection was to demonstrate any reduction in PTV or GTV coverage as a result of
perceived necessity to lower dose to the optic chiasm.
Independent Testing
The first hypothesis was tested with an independent-samples t-test to compare the Dice
coefficients of each participant contour to the expert’s contour. The t-test utilizes the
hypothetical mean, the number of participants, and the standard deviation. The second
hypothesis was tested with a t-test for 2 independent means comparing the differences of the
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maximum dose for the optic chiasm between the participant and expert’s contour. The testing
threshold for significance was P < 0.05.
Results
Variation Between Optic Chiasm Contours
In comparison with the expert optic chiasm contour, the participant contours received
Dice scores varying between 0.15 and 0.76 (Table 1). The standard deviation was 0.17, with a
mean score of 0.49. With 16 participants, it was found that there was significant variance
between contours (t (15) = 10.343, P < 0.001 when ALPHA = 0.5); therefore, the first null
hypothesis, that (H10) there will not be statistically significant variation between the optic chiasm
contours of participants and expert contours of published contouring guidelines, was rejected.
Variation in Dose Between Optic Chiasm Contours
For the participant contour plans, the maximum dose varied between 5510.7 cGy and
5540.5 cGy whereas the corresponding maximum doses that each of these plans delivered to the
expert contour varied between 5524 cGy and 5685.8 cGy (Table 2 and Figure 1). The maximum
dose of the participant contours had a standard deviation of 14.57 cGy, a mean dose of 5538
cGy, and a range of 53.9 cGy compared to a standard deviation of 50 cGy, a mean dose of
5582.3 cGy, and a range of 161.8 of the expert contour plan (Table 2). The difference in
maximum dose between the participant contour and the corresponding expert contour varied
between - 40.6 cGy and 141.4 cGy, with a standard deviation of 55.2 cGy and a mean of 44.4
cGy (Table 2). The percentage difference in maximum point dose between the participant
contour plans and the corresponding expert contour plan varied between - 0.72% and 2.56% for a
range of 3.29% (Table 2). In 12 of the 16 participant contour plans, the expert contour received a
higher dose than the participant contour. When the dose to the expert optic chiasm contour was
measured in the participant optic chiasm contour generated plan, the expert optic chiasm contour
received a higher dose 75% of the time (Table 2).
The difference in maximum dose to the optic chiasm was evaluated for statistical
significance. The t-test for 2 dependent means was used. The doses of the participants and expert
contours were evaluated and inputted into the calculation. There was significantly higher doses
in the expert contour (M = 5582 cGy, SD = 52) compared to the participant (M = 5538 cGy, SD
= 15); t(15) = 3.06, P < 0.004 when ALPHA = 0.5 which indicated that there is there is a
significant chance of the patient’s optic chiasm receiving higher dose if participant contours do
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not conform to expert standards. Therefore, the second null hypothesis (H20) that the variation in
contouring of the optic chiasm results in higher maximum dose to the expert optic chiasm
contours compared to the participant’s contoured optic chiasm, was rejected.
Dose to PTV/GTV
The percentage of the PTV covered by the prescription dose varied between 25.6% and
70.4% with a range of 44.8% and a standard deviation of 12.6% (Table 3). The mean percentage
of PTV covered by prescription dose was 50.6% (Table 3). The percentage of the GTV covered
by prescription dose varied between 16.4% and 73.1% with a range of 56.7% and a standard
deviation of 16.2% (Table 3). The mean percentage of the GTV covered by prescription dose
was 51.9% (Table 3). The minimum PTV dose varied between 5338.8 cGy and 5401.2 cGy with
a range of 62.4 cGy (Table 3). The mean minimum dose to the PTV was 5369.8 cGy, or 90.4%
of the prescription dose (Table 3). The minimum GTV dose varied between 5456.2 cGy and
5521.6 cGy for a range of 65.4cGy (Table 3). The mean minimum GTV dose was 5482.4 cGy or
92.3% of the prescription dose (Table 3).
Discussion
The conclusions of Vogin et al5 about the highly variable nature of participant optic
chiasm contours compared to established contouring guidelines were confirmed by the current
research. With a mean Dice Score of 0.49 for expert versus participant and 0.47 for intra-
contour, there is < 50% agreement between a participant contour and the expert or any other
participant contour. This demonstrates that not only are the participant contours significantly
different from the expert contour, but that there is a lack of consistency even within the way in
which participants contoured the optic chiasm. Participant contours were often significantly
larger than the expert contour and encompassed not only the optic chiasm but also followed the
optic nerves posteriorly and anteriorly from the chiasm. In comparison, the posterior and anterior
sections of the chiasm were often under-contoured, despite the larger overall size of the
participant contour (Figure 2). In 75% of cases, the median, mean, maximum and minimum
doses were higher for the expert contour than for the participant contour and the range of the
dose was roughly 3 times greater as well. The mean dose to the expert was 44 cGy higher than
the mean dose to the participant contour. These data indicate that, in 75% of cases, the
anatomical optic chiasm received a dose that was higher than the plan would have indicated
based on the inaccurately drawn optic chiasm. This is important as it may result in the optic
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chiasm receiving a dose exceeding limit while an inaccurate optic chiasm contour displays a
tolerance within the constraint.
Due to the proximity of the PTV to the chiasm and a PTV prescription dose in excess of
the 5500 cGy chiasm constraint, PTV coverage suffered. The mean coverage was 50.6% for the
PTV and 51.9% for the GTV, with the maximum coverage not exceeding 70.4% for PTV and
73.1% for GTV. The expert contour’s volume was 0.26 cubic centimeters (cc) while the mean
volume for participant contours was 0.49 cc. There is also a potential reduction of dose to the
PTV/GTV from erroneously large contours. In addition to expanded margins of the chiasm itself,
the often seen anterior and posterior extensions following the optic nerves may result in further
loss of coverage due to dose shaping difficulties or reduction in usable angles.
Conclusion
The research problem is that contours of the optic chiasm vary between institutions and
individuals, which can result in different doses to the anatomic structure. While other researchers
have examined the variability in dose due to variations in contours for other OAR, the potential
dose variations for the optic chiasm were unknown. The purpose of this study was to determine
the dose variance caused by differing optic chiasm contours compared to published contouring
guidelines. The results of the study demonstrated a great degree of variability between
participant contours and established contouring guidelines. In addition, these results
demonstrated that the variability of contours resulted in the expert contour receiving a higher
dose than the participant’s contours in 75% of cases. The clinical significance of this research is
that variability in contouring can result in inaccurate representation of dose to the optic chiasm,
which may, in turn, result in over-dose to the actual optic chiasm of patients and/or compromised
target dose coverage.
The limitations of this study included a limited sample size (n=16) of participant contours
as well as the use of a single plan instead of multiple iterations on separate plans. The study was
also reliant upon a single expert contour meant to represent the actual anatomical optic chiasm.
Though this contour was created with published contouring guidelines, it is still somewhat
subjective on the part of the radiation oncologist who created the expert contours. Future
research should include a larger sample size and an expert contour created with the input of
multiple physicians, particularly radiologists and radiation oncologists.
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Acknowledgements
We would like to thank the Statistical Consulting Center at UW-La Crosse for its
assistance with data analyses; however, any errors of fact or interpretation remain the sole
responsibly of the authors.
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of AAPM task group 101. Med Phys. 2010;37(8):4078-4101.
2. Bentzen SM, Constine LS, Deasy JO, et al. Quantitative Analyses of Normal Tissue Effects
in the Clinic (QUANTEC): an introduction to the scientific issues. Int J Radiat Oncol Biol
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3. Optic chiasm. National Cancer Institute.
https://www.cancer.gov/publications/dictionaries/cancer-terms/def/optic-chiasma. Accessed
on August 3, 2021
4. Parravano JG, Toledo A, Kucharczyk W. Dimensions of the optic nerves, chiasm, and tracts:
MR quantitative comparison between patients with optic atrophy and normals. J Comput
Assist Tomogr. Sep-Oct 1993;17(5):688-90. https://doi.org/10.1097/00004728-199309000-
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5. Vogin G, Hettal L, Bartau C, et al. Cranial organs at risk delineation: heterogenous practices
in radiotherapy planning. Radiat Oncol. 2021;16(1). https://doi.org/10.1186/s13014-021-
01756-y
6. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med. 2012 Oct; 22(3): 276–
282. PMCID: PMC3900052
7. Clayton R, Carlisle J, Asim B, Popple RA. Contouring challenges in radiation oncology:
delineating the optic chiasm. Int J Radiat Oncol Biol Phys. 2016;96(2):E82.
https://doi.org/10.1016/j.ijrobp.2016.06.798
8. Wright JL, Yom SS, Awan MJ, et al. Standardizing normal tissue contouring for radiation
therapy treatment planning: an ASTRO consensus paper. Pract Radiat Oncol. 2019;9(2):65-
72. https://doi.org/10.1016/j.prro.2018.12.003
9. Loo SW, Martin WMC, Smith P, Cherian S, Rogues TW. Interobserver variation in parotid
gland delineation: a study of its impact on intensity-modulated radiotherapy solutions with a
systematic review of the literature. Br J Radiol. 2012;85(1016):1070–1077.
https://doi.org/10.1259/bjr/32038456
10. Nelms BE, Tome 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):368-78. https://doi.org/10.1016/j.ijrobp.2010.10.019
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11. Martel MK, Sandler HM, Cornblath WT, et al. Dose-volume complication analysis for visual
pathway structures of patients with advanced paranasal sinus tumors. Int J Radiat Oncol Biol
Phys. 1997;38(2):273-284. https://doi.org/10.1016/S0360-3016(97)00029-1
12. Chi A, Nguyen NP, Tse W, Sobremonte G, Concannon P, Zhu A. Intensity modulated
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Hematol Oncol. 2013;6:4. https://doi.org/10.1186/1756-8722-6-4
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Figures

5750

5700

5650

5600
Dose in cGy

5550

5500

5450

5400
0 4 8 12 16
Participant Contour plan Participant Expert

Figure 1. Corresponding maximum dose to the expert contour in participant contour plans and
maximum dose of each participant contour.
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Figure 2. All participant contours overlaid on bolded (dark blue) expert contour.
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Tables

Table 1. Expert contour versus participant contour Dice scores

Participant Participant vs Expert
Contour Dice Coefficient Score
1 0.368
2 0.669
3 0.436
4 0.760
5 0.331
6 0.290
7 0.301
8 0.159
9 0.470
10 0.739
11 0.528
12 0.570
13 0.600
14 0.484
15 0.508
16 0.624

Table 2. Dose to participant optic chiasm contours.

Participant Participant Expert Dose Difference Difference Participant Expert
Contours Dose Maximum between (%) Dose Mean Dose
Maximum (cGy)* Contours (cGy)* Mean
(cGy)* (cGy)*
SD 14.57 50 55.2 0.99 231.6 117.8
Mean 5538.3 5582.3 44.4 0.80 5034 5386.7
Median 5540.5 5557.1 30.35 0.54 5068 5357.9
Range 53.9 (0.9%) 161.8 (2.7%) 182 3.29 787.3 514.1
Minimum 5510.7 5524 -40.6 -0.72 4573.7 5321.3
Maximum 5564.6 5685.8 141.4 2.5 5361 5835.4
*centi-gray (cGy); standard deviation (SD)
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Table 3. Dose coverage to PTV with participant contours

Participant PTV* GTV* Minimum Minimum Hot Spot
Contours Prescription Prescription PTV* Dose GTV* Dose (%)
Coverage (%) Coverage (%) (cGy)* (cGy)*
SD* 12.60 16.20 19.5 21.3 0.70%
Mean 50.6 51.9 5369.8 5482.4 105.5
Median 53.2 56.2 5369.55 5478.1 105.7
Range 44.8 56.7 62.4 65.4 2.5
Minimum 25.6 16.4 5338.8 5456.2 103.9
Maximum 70.4 73.1 5401.2 5521.6 106.4
*centi-gray (cGy); planning treatment volume (PTV); gross tumor volume (GTV); standard deviation (SD)