TotalSynth: Robust Whole-Body Synthetic CT from MRI and CBCT

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 $γ_{2\%/2\text{mm}}>98\%$, proton $γ\approx85\%$. Task 2 improved: MAE $48.3\pm13.4$ HU, PSNR 32.6 dB, MS-SSIM 0.968, Dice 0.86, photon $γ>99\%$, proton $γ\approx89\%$. Strong image--segmentation correlations ($ρ=0.78$--$0.79$) 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.

Accurate synthesis of computed tomography (CT) images from magnetic resonance imaging (MRI) is clinically valuable for cranial applications such as attenuation correction, radiotherapy planning, and image-guided interventions. However, heterogeneity across MRI field strengths and acquisition protocols limits the generalizability of existing methods. In this study, we formulate cranial CT synthesis as a modular, structurally coupled problem and propose a deep learning framework to improve robustness across heterogeneous MRI conditions. The model is designed to adapt to variations in field strength and imaging protocols while preserving anatomical consistency. Experiments on multi-site datasets demonstrate improved performance and generalization compared with conventional approaches. The proposed method enables reliable CT synthesis across heterogeneous MRI settings, supporting broader clinical translation.

Accurate MRI-to-CT synthesis could enable MR-only pelvic workflows by providing CT-like images with bone details while avoiding additional ionizing radiation. In this work, we investigate recently proposed drifting models for synthesizing pelvis CT images from MRI and benchmark them against convolutional neural networks (UNet, VAE), a generative adversarial network (WGAN-GP), a physics-inspired probabilistic model (PPFM), and diffusion-based methods (FastDDPM, DDIM, DDPM). Experiments are performed on two complementary datasets: Gold Atlas Male Pelvis and the SynthRAD2023 pelvis subset. Image fidelity and structural consistency are evaluated with SSIM, PSNR, and RMSE, complemented by qualitative assessment of anatomically critical regions such as cortical bone and pelvic soft-tissue interfaces. Across both datasets, the proposed drifting model achieves high SSIM and PSNR and low RMSE, surpassing strong diffusion baselines and conventional CNN-, VAE-, GAN-, and PPFM-based methods. Visual inspection shows sharper cortical bone edges, improved depiction of sacral and femoral head geometry, and reduced artifacts or over-smoothing, particularly at bone-air-soft tissue boundaries. Moreover, the drifting model attains these gains with one-step inference and inference times on the order of milliseconds, yielding a more favorable accuracy-efficiency trade-off than iterative diffusion sampling while remaining competitive in image quality. These findings suggest that drifting models are a promising direction for fast, high-quality pelvic synthetic CT generation from MRI and warrant further investigation for downstream applications such as MRI-only radiotherapy planning and PET/MR attenuation correction.