A Privacy-Preserving Federated Learning Framework for Generalizable CBCT to Synthetic CT Translation in Head and Neck

Shortened Abstract Cone-beam computed tomography (CBCT) has become a widely adopted modality for image-guided radiotherapy (IGRT). However, CBCT suffers from increased noise, limited soft-tissue contrast, and artifacts, resulting in unreliable Hounsfield unit values and hindering direct dose calculation. Synthetic CT (sCT) generation from CBCT addresses these issues, especially using deep learning (DL) methods. Existing approaches are limited by institutional heterogeneity, scanner-dependent variations, and data privacy regulations that prevent multi-center data sharing. To overcome these challenges, we propose a cross-silo horizontal federated learning (FL) approach for CBCT-to-sCT synthesis in the head and neck region, extending our FedSynthCT framework. A conditional generative adversarial network was collaboratively trained on data from three European medical centers in the public SynthRAD2025 challenge dataset. The federated model demonstrated effective generalization across centers, with mean absolute error (MAE) ranging from 64.38±13.63 to 85.90±7.10 HU, structural similarity index (SSIM) from 0.882±0.022 to 0.922±0.039, and peak signal-to-noise ratio (PSNR) from 32.86±0.94 to 34.91±1.04 dB. Notably, on an external validation dataset of 60 patients, comparable performance was achieved (MAE: 75.22±11.81 HU, SSIM: 0.904±0.034, PSNR: 33.52±2.06 dB) without additional training, confirming robust generalization despite protocol, scanner differences and registration errors. These findings demonstrate the technical feasibility of FL for CBCT-to-sCT synthesis while preserving data privacy and offer a collaborative solution for developing generalizable models across institutions without centralized data sharing or site-specific fine-tuning.