Generating synthetic computed tomography for radiotherapy: SynthRAD2025 challenge report

TL;DR

SynthRAD2025 benchmarked deep learning methods for generating synthetic CT images from MRI and CBCT scans across multiple European centers, demonstrating clinical relevance but highlighting ongoing challenges in dose accuracy and tissue interface errors.

Contribution

This study provides a large-scale, multi-center benchmark of deep learning sCT methods, emphasizing the importance of dose-based evaluation for clinical validation.

Findings

Deep learning methods achieved clinically relevant sCT quality, especially for CBCT-to-CT.

Image quality correlates strongly with segmentation accuracy but less with dosimetric accuracy.

Head-and-neck cases showed more consistent results than thoracic and abdominal cases.

Abstract

Radiation therapy (RT) requires precise dose delivery over multiple fractions, with CT fundamental for treatment planning due to its electron density information. Repeated CT acquisitions impose radiation exposure and logistical burdens, MRI lacks electron density, and cone-beam CT (CBCT) requires correction for dose calculation. Synthetic CT (sCT) generation addresses these by converting MRI or CBCT into CT-equivalent images with accurate Hounsfield Unit (HU) values, enabling MRI-only RT and CBCT-based adaptive workflows. Building on SynthRAD2023, SynthRAD2025 benchmarked sCT methods on 2,362 patients from five European centers across head and neck, thorax, and abdomen. Two tasks: MRI-to-CT (890 cases) and CBCT-to-CT (1,472 cases), evaluated via image similarity (MAE, PSNR, MS-SSIM), segmentation (Dice, HD95), and dosimetric metrics from photon and proton plans. With 803 participants and 12/13 valid submissions, Task 1 top performance reached MAE $64.8\pm21.3$ HU, PSNR $\sim$30 dB, MS-SSIM $\sim$0.936, Dice 0.79, photon $\gamma_{2\%/2\text{mm}}>98\%$, proton $\gamma\approx85\%$. Task 2 improved: MAE $48.3\pm13.4$ HU, PSNR 32.6 dB, MS-SSIM 0.968, Dice 0.86, photon $\gamma>99\%$, proton $\gamma\approx89\%$. Strong image--segmentation correlations ($\rho=0.78$--$0.79$) but moderate dose correlations confirmed image quality is insufficient as a dosimetric surrogate. Head-and-neck cases were most consistent; thoracic and abdominal cases showed greater variability. Residual errors at tissue interfaces propagate along beam paths, affecting proton dose more than photon. SynthRAD2025 demonstrates that deep learning yields clinically relevant sCTs, especially for CBCT-to-CT, while identifying persistent MRI-to-CT challenges and underscoring dose-based evaluation as essential for clinical validation.