A Unified Generation-Registration Framework for Improved MR-based CT Synthesis in Proton Therapy

Background: In MR-guided proton therapy planning, aligning MR and CT images is key for MR-based CT synthesis, especially in mobile regions like the head-and-neck. Misalignments here can lead to less accurate synthetic CT (sCT) images, impacting treatment precision. Purpose: This study introduces a novel network that cohesively unifies image generation and registration processes to enhance the quality and anatomical fidelity of sCTs derived from better-aligned MR images. Methods: The approach synergizes a generation network (G) with a deformable registration network (R), optimizing them jointly in MR-to-CT synthesis. This goal is achieved by alternately minimizing the discrepancies between the generated/registered CT images and their corresponding reference CT counterparts. The generation network employs a UNet architecture, while the registration network leverages an implicit neural representation of the Deformable Vector Fields (DVFs). We validated this method on a dataset comprising 60 Head-and-Neck patients, reserving 12 cases for holdout testing. Results: Compared to the baseline Pix2Pix method with MAE 124.95\pm 30.74 HU, the proposed technique demonstrated 80.98\pm 7.55 HU. The unified translation-registration network produced sharper and more anatomically congruent outputs, showing superior efficacy in converting MR images to sCTs. Additionally, from a dosimetric perspective, the plan recalculated on the resulting sCTs resulted in a remarkably reduced discrepancy to the reference proton plans. Conclusions: This study conclusively demonstrates that a holistic MR-based CT synthesis approach, integrating both image-to-image translation and deformable registration, significantly improves the precision and quality of sCT generation, particularly for the challenging body area with varied anatomic changes between corresponding MR and CT.