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Background: MRI‐guided radiation therapy (MRgRT) requires unique quality assurance equipment to address MR‐compatibility needs, minimize electron return effect, handle complex dose distributions, and evaluate real‐time dosimetry for gating. Plastic scintillation detectors (PSDs) are an attractive option to address these needs. Purpose: To perform a comprehensive characterization of a multi‐probe PSD system in a low‐field 0.35 T MR‐linac, including detector response assessment and gating performance. Methods: A four‐channel PSD system (HYPERSCINT RP‐200) was assembled. A single channel was used to evaluate repeatability, percent depth dose (PDD), detector response as a function of orientation with respect to the magnetic field, and intersession variability. All four channels were used to evaluate repeatability, linearity, and output factors. The four PSDs were integrated into an MR‐compatible motion phantom at isocenter and in gradient regions. Experiments were conducted to evaluate gating performance and tracking efficacy. Results: For repeatability, the maximum standard deviation of repeated measurements was 0.13% (single PSD). Comparing the PSD to reference data, PDD had a maximum difference of 1.12% (10 cm depth, 6.64 × 6.64 cm2). Percent differences for rotated detector setups were negligible (< 0.3%). All four PSDs demonstrated linear response over 10–1000 MU delivered and the maximum percent difference between the baseline and measured output factors was 0.78% (2.49 × 2.49 cm2). Gating experiments had 400 cGy delivered to isocenter with < 0.8 cGy variation for central axis measures and < 0.7 cGy for the gradient sampled region. Real‐time dosimetry measurements captured spurious beam‐on incidents that correlated to tracking algorithm inaccuracies and highlighted gating parameter impact on delivery efficiency. Conclusions: Characterization of the multi‐point PSD dosimetry system in a 0.35 T MR‐linac demonstrated reliability in a low‐field MR‐Linac setting, with high repeatability, linearity, small intersession variability, and similarity to baseline data for PDD and output factors. Time‐resolved, multi‐point dosimetry also showed considerable promise for gated MR‐Linac applications. [ABSTRACT FROM AUTHOR]

Background: MRI‐Linac systems enable daily diffusion‐weighed imaging (DWI) MRI scans for assessing glioblastoma tumor changes with radiotherapy treatment. Purpose: Our study assessed the image quality of echoplanar imaging (EPI)‐DWI scans compared with turbo spin echo (TSE)‐DWI scans at 0.35 Tesla (T) and compared the apparent diffusion coefficient (ADC) values and distortion of EPI‐DWI on 0.35 T MRI‐Linac compared to high‐field diagnostic MRI scanners. Methods: The calibrated National Institute of Standards and Technology (NIST)/Quantitative Imaging Biomarkers Alliance (QIBA) Diffusion Phantom was scanned on a 0.35 T MRI‐Linac, and 1.5 T and 3 T MRI with EPI‐DWI. Five patients were scanned on a 0.35 T MRI‐Linac with a TSE‐DWI sequence, and five other patients were scanned with EPI‐DWI on a 0.35 T MRI‐Linac and a 3 T MRI. The quality of images was compared between the TSE‐DWI and EPI‐DWI on the 0.35 T MRI‐Linac assessing signal‐to‐noise ratios and presence of artifacts. EPI‐DWI ADC values and distortion magnitude were measured and compared between 0.35 T MRI‐Linac and high‐field MRI for both phantom and patient studies. Results: The average ADC differences between EPI‐DWI acquired on the 0.35 T MRI‐Linac, 1.5 T and 3 T MRI scanners and published references in the phantom study were 1.7%, 0.4% and 1.0%, respectively. Comparing the ADC values based on EPI‐DWI in glioblastoma tumors, there was a 3.36% difference between 0.35 and 3 T measurements. Susceptibility‐induced distortions in the EPI‐DWI phantoms were 0.46 ± 1.51 mm for 0.35 MRI‐Linac, 0.98 ± 0.51 mm for 1.5 T MRI and 1.14 ± 1.88 mm for 3 T MRI; for patients ‐0.47 ± 0.78 mm for 0.35 T and 1.73 ± 2.11 mm for 3 T MRIs. The mean deformable registration distortion for a phantom was 1.1 ± 0.22 mm, 3.5 ± 0.39 mm and 4.7 ± 0.37 mm for the 0.35 T MRI‐Linac, 1.5 T MRI, and 3 T MRI scanners, respectively; for patients this distortion was –0.46 ± 0.57 mm for 0.35 T and 4.2 ± 0.41 mm for 3 T. EPI‐DWI 0.35 T MRI‐Linac images showed higher SNR and lack of artifacts compared with TSE‐DWI, especially at higher b‐values up to 1000 s/mm2. Conclusion: EPI‐DWI on a 0.35 T MRI‐Linac showed superior image quality compared with TSE‐DWI, minor and less distortions than high‐field diagnostic scanners, and comparable ADC values in phantoms and glioblastoma tumors. EPI‐DWI should be investigated on the 0.35 T MRI‐Linac for prediction of early response in patients with glioblastoma. [ABSTRACT FROM AUTHOR]

Background: Magnetic resonance imaging (MRI)‐guided radiotherapy with multileaf collimator (MLC)‐tracking is a promising technique for intra‐fractional motion management, achieving high dose conformality without prolonging treatment times. To improve beam‐target alignment, the geometric error due to system latency should be reduced by using temporal prediction. Purpose: To experimentally compare linear regression (LR) and long‐short‐term memory (LSTM) motion prediction models for MLC‐tracking on an MRI‐linac using multiple patient‐derived traces with different complexities. Methods: Experiments were performed on a prototype 1.0 T MRI‐linac capable of MLC‐tracking. A motion phantom was programmed to move a target in superior‐inferior (SI) direction according to eight lung cancer patient respiratory motion traces. Target centroid positions were localized from sagittal 2D cine MRIs acquired at 4 Hz using a template matching algorithm. The centroid positions were input to one of four motion prediction models. We used (1) a LSTM network which had been optimized in a previous study on patient data from another cohort (offline LSTM). We also used (2) the same LSTM model as a starting point for continuous re‐optimization of its weights during the experiment based on recent motion (offline+online LSTM). Furthermore, we implemented (3) a continuously updated LR model, which was solely based on recent motion (online LR). Finally, we used (4) the last available target centroid without any changes as a baseline (no‐predictor). The predictions of the models were used to shift the MLC aperture in real‐time. An electronic portal imaging device (EPID) was used to visualize the target and MLC aperture during the experiments. Based on the EPID frames, the root‐mean‐square error (RMSE) between the target and the MLC aperture positions was used to assess the performance of the different motion predictors. Each combination of motion trace and prediction model was repeated twice to test stability, for a total of 64 experiments. Results: The end‐to‐end latency of the system was measured to be (389 ± 15) ms and was successfully mitigated by both LR and LSTM models. The offline+online LSTM was found to outperform the other models for all investigated motion traces. It obtained a median RMSE over all traces of (2.8 ± 1.3) mm, compared to the (3.2 ± 1.9) mm of the offline LSTM, the (3.3 ± 1.4) mm of the online LR and the (4.4 ± 2.4) mm when using the no‐predictor. According to statistical tests, differences were significant (p‐value <0.05) among all models in a pair‐wise comparison, but for the offline LSTM and online LR pair. The offline+online LSTM was found to be more reproducible than the offline LSTM and the online LR with a maximum deviation in RMSE between two measurements of 10%. Conclusions: This study represents the first experimental comparison of different prediction models for MRI‐guided MLC‐tracking using several patient‐derived respiratory motion traces. We have shown that among the investigated models, continuously re‐optimized LSTM networks are the most promising to account for the end‐to‐end system latency in MRI‐guided radiotherapy with MLC‐tracking. [ABSTRACT FROM AUTHOR]

Simple Summary: MRI can provide better visualization of tumors and nearby organs at risk (OAR) than CT for fast and accurate contouring during online adaptive MRI-guided stereotactic body radiation treatment (MRI-guided SBRT) for pancreatic and other intra-abdominal cancers. Pre-set MRI sequences provided in a 1.5T MRI scanner hybrid with a linear accelerator can be used during MRI-guided SBRT, but they often limit tumor and OAR visualization and require a long image acquisition time. This study retrospectively analyzed 26 patients with pancreatic and intra-abdominal cancers that underwent CT and MR simulations and 3–5 fractionated MRI-guided SBRT. The visualization of tumors and OAR was improved with T1W imaging, which is essential for online adaptive planning and resulted in fast and accurate contouring in a shorter imaging time. A 1.5T MRI combined with a linear accelerator (Unity®, Elekta; Stockholm, Sweden) is a device that shows promise in MRI-guided stereotactic body radiation treatment (SBRT). Previous studies utilized the manufacturer's pre-set MRI sequences (i.e., T2 Weighted (T2W)), which limited the visualization of pancreatic and intra-abdominal tumors and organs at risk (OAR). Here, a T1 Weighted (T1W) sequence was utilized to improve the visualization of tumors and OAR for online adapted-to-position (ATP) and adapted-to-shape (ATS) during MRI-guided SBRT. Twenty-six patients, 19 with pancreatic and 7 with intra-abdominal cancers, underwent CT and MRI simulations for SBRT planning before being treated with multi-fractionated MRI-guided SBRT. The boundary of tumors and OAR was more clearly seen on T1W image sets, resulting in fast and accurate contouring during online ATP/ATS planning. Plan quality in 26 patients was dependent on OAR proximity to the target tumor and achieved 96 ± 5% and 92 ± 9% in gross tumor volume D90% and planning target volume D90%. We utilized T1W imaging (about 120 s) to shorten imaging time by 67% compared to T2W imaging (about 360 s) and improve tumor visualization, minimizing target/OAR delineation uncertainty and the treatment margin for sparing OAR. The average time-consumption of MRI-guided SBRT for the first 21 patients was 55 ± 15 min for ATP and 79 ± 20 min for ATS. [ABSTRACT FROM AUTHOR]

Simple Summary: Current auto-segmentation methods for glioblastoma utilize mainly pre-operative 1.5T and 3T MRI. The first commercial MRI-linear accelerator (linac) radiation treatment platform acquires low-field (0.35T) post-operative MRI at the delivery of each treatment. This study presents the first automatic brain lesion segmentation network developed for MRI-linac to track tumor changes during radiotherapy. The tumors and resection cavities are automatically segmented using a deep learning network, allowing for daily monitoring of tumor volume changes, creation of tools necessary for adaptive radiotherapy of glioblastoma, and providing MRI regions of interest for further analyses that may discover prognostic markers. Glioblastoma changes during chemoradiotherapy are inferred from high-field MRI before and after treatment but are rarely investigated during radiotherapy. The purpose of this study was to develop a deep learning network to automatically segment glioblastoma tumors on daily treatment set-up scans from the first glioblastoma patients treated on MRI-linac. Glioblastoma patients were prospectively imaged daily during chemoradiotherapy on 0.35T MRI-linac. Tumor and edema (tumor lesion) and resection cavity kinetics throughout the treatment were manually segmented on these daily MRI. Utilizing a convolutional neural network, an automatic segmentation deep learning network was built. A nine-fold cross-validation schema was used to train the network using 80:10:10 for training, validation, and testing. Thirty-six glioblastoma patients were imaged pre-treatment and 30 times during radiotherapy (n = 31 volumes, total of 930 MRIs). The average tumor lesion and resection cavity volumes were 94.56 ± 64.68 cc and 72.44 ± 35.08 cc, respectively. The average Dice similarity coefficient between manual and auto-segmentation for tumor lesion and resection cavity across all patients was 0.67 and 0.84, respectively. This is the first brain lesion segmentation network developed for MRI-linac. The network performed comparably to the only other published network for auto-segmentation of post-operative glioblastoma lesions. Segmented volumes can be utilized for adaptive radiotherapy and propagated across multiple MRI contrasts to create a prognostic model for glioblastoma based on multiparametric MRI. [ABSTRACT FROM AUTHOR]

Magnetic resonance imaging (MRI) has become an important imaging modality in the field of radiotherapy (RT) in the past decade, especially with the development of various novel MRI and image‐guidance techniques. In this review article, we will describe recent developments and discuss the applications of multi‐parametric MRI (mpMRI) in RT simulation. In this review, mpMRI refers to a general and loose definition which includes various multi‐contrast MRI techniques. Specifically, we will focus on the implementation, challenges, and future directions of mpMRI techniques for RT simulation. [ABSTRACT FROM AUTHOR]

Purpose: To propose a novel magnetic field dose calculation method based on transformation from pencil beam (PB) to Monte Carlo (MC) distribution for MRI-Linac online treatment planning. Methods: The novel magnetic field dose calculation algorithm was established by a PB dose engine and a magnetic field with tissue inhomogeneity influence correction network. The correction network was constructed with a Res-UNet framework, including residual modules and an encoding–decoding path, by inputting three-dimensional PB dose and patient electron density map, and outputting transformed dose distribution. The influences of magnetic fields and tissue heterogeneity were considered and corrected simultaneously in the correction model. A total of 110 clinically treated static beam IMRT plans were collected, including plans for brain, head-and-neck, lung, and rectum cases. A total of 90 cases were used and enhanced to train and validate the model, and the other 20 cases were for test.By comparing the proposed pipeline-generated dose distribution with original input PB dose and corresponding MC dose, the feasibility and effectiveness of the method was evaluated. Results: Results on both beam dose and plan dose accuracy comparisons on all investigated four tumor sites show great consistency between the crossdose-engine transformation generations and the MC results,with averaged plan mean absolute error of 0.90% ± 0.13% for the voxel-wise dose difference and 98.33% ± 1.07% gamma passing rate at the 2%/2 mm criteria. The whole PB calculation and transformation process can be completed within second. Conclusions: We have successfully developed a fast novel magnetic field dose calculation pipeline based on transformation from PB distribution to MC distribution for MRI-Linac online treatment planning. [ABSTRACT FROM AUTHOR]

Background: Rotation of the ferromagnetic gantry of a low magnetic field MRI–Linac was previously demonstrated to cause large center frequency offsets of ±400 Hz. The B0 off‐resonances cause image artifacts and imaging isocenter shifts that would preclude MRI‐guided arc therapy. Purpose: The purpose of this study was to measure and compensate for center frequency offsets in real time during gantry rotation on a 0.35‐T MRI–Linac using a free induction decay (FID) navigator. Methods: A nonselective FID navigator was added before each 2D balanced steady‐state free precession cine image acquisition on a 0.35‐T MRI–Linac. Images were acquired at 7.3 frames per second. Phase data from the initial FID navigator (while the gantry was stationary) was used as a reference. The phase data from each subsequent FID navigator was used to calculate the real‐time B0 off‐resonance. The transmitter/receiver phase and the phase accrual over the adjacent image acquisition were adjusted to correct for the center frequency offset. Measurements were performed using an MRI–Linac dynamic phantom prior to and while the gantry rotated clockwise and counterclockwise. Image quality and signal‐to‐noise ratio (SNR) were compared between uncorrected and B0‐corrected MRIs using a reference image acquired while the gantry was stationary. Four targets in the phantom were manually contoured on the first image frame, and an active contouring algorithm was used retrospectively on each subsequent frame to assess image variations and calculate Dice coefficients. Additionally, three healthy volunteers were imaged using the same pulse sequences with and without real‐time B0 compensation during gantry rotation. Normalized root mean square errors (nRMSEs) were calculated for the phantom and in vivo to assess the efficacy of the B0 compensation on image quality. The measured center frequency offsets from the volunteer and MRI dynamic phantom navigator data were also compared. The sinusoidal behavior of the center frequency offsets was modeled based on the gantry layout and long‐time constant eddy currents resulting from gantry rotation. Results: The duration of the FID navigator and processing was 4.5 ms. The FID navigator resulted in a ≤11% drop in SNR in the phantom and in vivo (liver). Dice coefficients from the MRI‐guided radiation therapy (MR‐IGRT) phantom contour measurements remained above 0.8 with B0 compensation. Without B0 compensation, the Dice coefficients dropped below 0.8 for up to 21% of the time depending on the contour. Real‐time B0 compensation resulted in mean reductions in nRMSE of 51% and 16% for the MR‐IGRT phantom and in vivo, respectively. Peak‐to‐peak center frequency offsets ranged from 757 to 773 Hz in the phantom and 760 to 871 Hz in vivo. Conclusion: Dynamic real‐time B0 compensation significantly improved image quality and reduced artifacts during gantry rotation in the phantom and in vivo. However, the FID navigator resulted in a small drop in the imaging duty cycle and SNR. [ABSTRACT FROM AUTHOR]

• One of few prospective phase II studies evaluating SBRT with ablative doses. • MRI-guided SBRT is safe and well tolerated. • SBRT can benefit certain patients with LAPC. Stereotactic body radiotherapy (SBRT) has emerged as a promising new modality for locally advanced pancreatic cancer (LAPC). The current study evaluated the efficacy and toxicity of SBRT in patients with LAPC (NCT03648632). This prospective single institution phase II study recruited patients with histologically or cytologically proven adenocarcinoma of the pancreas after more than two months of combination chemotherapy with no sign of progressive disease. Patients were prescribed 50–60 Gy in 5–8 fractions. Patients were initially treated on a standard linac (n = 4). Since 2019, patients were treated using online magnetic resonance (MR) image-guidance on a 1.5 T MRI-linac, where the treatment plan was adapted to the anatomy of the day. The primary endpoint was resection rate. Twenty-eight patients were enrolled between August 2018 and March 2022. All patients had non-resectable disease at time of diagnosis. Median follow-up from inclusion was 28.3 months (95 % CI 24.0-NR). Median progression-free and overall survival from inclusion were 7.8 months (95 % CI 5.0–14.8) and 16.5 months (95 % CI 10.7–22.6), respectively. Six patients experienced grade III treatment-related adverse events (jaundice, nausea, vomiting and/or constipation). One of the initial four patients receiving treatment on a standard linac experienced a grade IV perforation of the duodenum. Six patients (21 %) underwent resection. A further one patient was offered resection but declined. This study demonstrates that SBRT in patients with LAPC was associated with promising overall survival and resection rates. Furthermore, SBRT was safe and well tolerated, with limited severe toxicities. [ABSTRACT FROM AUTHOR]

• MRI-guided tracking of atrial fibrillation cardiac radioablation targets. • Investigating a cardiac motion compensation technique for cardiac radioablation. • Tracking performance in atrial fibrillation and healthy participants was comparable. • Results of this study warrant the further investigation of this technique. Atrial fibrillation (AF) cardiac radioablation (CR) challenges radiotherapy tracking: multiple small targets close to organs-at-risk undergo rapid differential cardiac contraction and respiratory motion. MR-guidance offers a real-time target tracking solution. This work develops and investigates MRI-guided tracking of AF CR targets with cardiac-induced motion. A direct tracking method (Tracking direct) and two indirect tracking methods leveraging population-based surrogacy relationships with the left atria (Tracking indirect_LA) or other target (Tracking indirect_target) were developed. Tracking performance was evaluated using transverse ECG-gated breathhold MRI images from 15 healthy and 10 AF participants. Geometric and volumetric tracking errors were calculated, defined as the difference between the ground-truth and tracked target centroids and volumes respectively. Transverse, breath-hold, noncardiac-gated cine images were acquired at 4 Hz in 5 healthy and 5 AF participants to qualitatively characterize tracking performance on images more comparable to MRILinac acquisitions. The average 3D geometric tracking errors for Tracking direct , Tracking indirect_LA and Tracking indirect_target respectively were 1.7 ± 1.2 mm, 1.6 ± 1.1 mm and 1.9 ± 1.3 mm in healthy participants and 1.7 ± 1.3 mm, 1.5 ± 1.0 mm and 1.7 ± 1.2 mm in AF participants. For Tracking direct , 88% of analyzed images had 3D geometric tracking errors <3 mm and the average volume tracking error was 1.7 ± 1.3 cc. For Tracking direct on non-cardiac-gated cine images, tracked targets overlapped organsat-risk or completely missed the target area on 2.2% and 0.08% of the images respectively. The feasibility of non-invasive MRI-guided tracking of cardiac-induced AF CR target motion was demonstrated for the first time, showing potential for improving AF CR treatment efficacy. [ABSTRACT FROM AUTHOR]

Purpose: The hybrid system combining a magnetic resonance imaging (MRI) scanner with a linear accelerator (Linac) has become increasingly desirable for tumor treatment because of excellent soft tissue contrast and nonionizing radiation. However, image distortions caused by gradient nonlinearity (GNL) can have detrimental impacts on real‐time radiotherapy using MRI‐Linac systems, where accurate geometric information of tumors is essential. Methods: In this work, we proposed a deep convolutional neural network‐based method to efficiently recover undistorted images (ReUINet) for real‐time image guidance. The ReUINet, based on the encoder‐decoder structure, was created to learn the relationship between the undistorted images and distorted images. The ReUINet was pretrained and tested on a publically available brain MR image dataset acquired from 23 volunteers. Then, transfer learning was adopted to implement the pretrained model (i.e., network with optimal weights) on the experimental three‐dimensional (3D) grid phantom and in‐vivo pelvis image datasets acquired from the 1.0 T Australian MRI‐Linac system. Results: Evaluations on the phantom (768 slices) and pelvis data (88 slices) showed that the ReUINet achieved improvement over 15 times and 45 times on computational efficiency in comparison with standard interpolation and GNL‐encoding methods, respectively. Moreover, qualitative and quantitative results demonstrated that the ReUINet provided better correction results than the standard interpolation method, and comparable performance compared to the GNL‐encoding approach. Conclusions: Validated by simulation and experimental results, the proposed ReUINet showed promise in obtaining accurate MR images for the implementation of real‐time MRI‐guided radiotherapy. [ABSTRACT FROM AUTHOR]

Over the last few years, magnetic resonance image‐guided radiotherapy systems have been introduced into the clinic, allowing for daily online plan adaption. While quality assurance (QA) is similar to conventional radiotherapy systems, there is a need to introduce or modify measurement techniques. As yet, there is no consensus guidance on the QA equipment and test requirements for such systems. Therefore, this report provides an overview of QA equipment and techniques for mechanical, dosimetric, and imaging performance of such systems and recommendation of the QA procedures, particularly for a 1.5T MR‐linac device. An overview of the system design and considerations for QA measurements, particularly the effect of the machine geometry and magnetic field on the radiation beam measurements is given. The effect of the magnetic field on measurement equipment and methods is reviewed to provide a foundation for interpreting measurement results and devising appropriate methods. And lastly, a consensus overview of recommended QA, appropriate methods, and tolerances is provided based on conventional QA protocols. The aim of this consensus work was to provide a foundation for QA protocols, comparative studies of system performance, and for future development of QA protocols and measurement methods. [ABSTRACT FROM AUTHOR]

Purpose: The treatment margins for lung stereotactic body radiotherapy (SBRT) are often large to cover the tumor excursions resulting from respiration, such that underdosage of the tumor can be avoided. Magnetic resonance imaging (MRI)‐guided multi‐leaf collimator (MLC) tracking can potentially reduce the influence of respiration to allow for smaller treatment margins. However, tracking is accompanied by system latency that may induce residual tracking errors. Alternatively, a simpler mid‐position delivery combined with trailing can be used. Trailing reduces influences of respiration by compensating for baseline motion, to potentially improve target coverage. In this study, we aim to show the feasibility of MRI‐guided tracking and trailing to reduce influences of respiration during lung SBRT. Methods: We implemented MRI‐guided tracking on the MR‐linac using an Elekta research tracking interface to track tumor motion during intensity modulated radiotherapy (IMRT). A Quasar MRI4D phantom was used to generate Lujan motion (cos4, 4 s period, 20 mm peak‐to‐peak amplitude) with and without 1.0 mm/min cranial drift. Phantom tumor positions were estimated from sagittal 2D cine‐MRI (4 or 8 Hz) using cross‐correlation‐based template matching. To compensate the anticipated system latency, a linear ridge regression predictor was optimized for online MRI by comparing two predictor training approaches: training on multiple traces and training on a single trace. We created 15‐beam clinical‐grade lung SBRT plans for central targets (8 × 7.5 Gy) and peripheral targets (3 × 18 Gy) with different PTV margins for mid‐position based motion management (3–5 mm) and for MLC tracking (3 mm). We used a film insert with a 3 cm spherical target to measure the spatial distribution and quantity of the delivered dose. A 1%/1 mm local gamma‐analysis quantified dose differences between motion management strategies and reference cases. Additionally, a dose area histogram (DAH) revealed the target coverage relative to the reference scenario. Results: The prediction filter gain was on average 25% when trained on multiple traces and 44% when trained on a single trace. The filter reduced system latency from 313 ± 2 ms to 0 ± 5 ms for 4 Hz imaging and from 215 ± 3 ms to 3 ± 3 ms for 8 Hz. The local gamma analysis for the central delivery showed that tracking improved the gamma pass‐rate from 23% to 96% for periodic motion and from 14% to 93% when baseline drift was applied. For the peripheral delivery during periodic motion, delivery pass‐rates improved from 22% to 93%. Comparing mid‐position delivery to trailing for periodic+drift motion increased the local gamma pass rate from 15% to 98% for a central delivery and from 8% to 98% for a peripheral delivery. Furthermore, the DAHs revealed a relative D98% GTV coverage of 101% and 97% compared to the reference scenario for, respectively, central and peripheral tracking of periodic+drift motion. For trailing, a relative D98% of 99% for central and 98% for peripheral trailing was found. Conclusions: We provided a first experimental demonstration of the technical feasibility of MRI‐guided MLC tracking and trailing for central and peripheral lung SBRT. Tracking maximizes the sparing of healthy tissue, while trailing is highly effective in mitigating baseline motion. [ABSTRACT FROM AUTHOR]

Purpose: High quality radiotherapy is challenging in cases where multiple targets with independent motion are simultaneously treated. A real‐time tumor tracking system that can simultaneously account for the motion of two targets was developed and characterized. Methods: The multitarget tracking system was implemented on a magnetic resonance imaging (MRI)‐linac and utilized multi‐leaf collimator (MLC) tracking to adapt the radiation beam to phantom targets reproducing motion with prostate and lung motion traces. Multitarget tracking consisted of three stages: (a) pretreatment aperture segmentation where the treatment aperture was divided into segments corresponding to each target, (b) MR imaging where the positions of the two targets were localized, and (c) MLC tracking where an updated treatment aperture was calculated. Electronic portal images (EPID) acquired during irradiation were analyzed to characterize geometric uncertainty and tracking latency. Results: Multitarget MLC tracking effectively accounted for the motion of both targets during treatment. The root‐mean‐square error between the centers of the targets and the centers of the corresponding MLC leaves were reduced from 5.5 mm without tracking to 2.7 mm with tracking for lung motion traces and reduced from 4.2 to 1.4 mm for prostate motion traces. The end‐to‐end latency of tracking was measured to be 328 ± 44 ms. Conclusions: We have demonstrated the first experimental implementation of MLC tracking for multiple targets having independent motion. This technology takes advantage of the imaging capabilities of MRI‐linacs and would allow treatment margins to be reduced in cases where multiple targets are simultaneously treated. [ABSTRACT FROM AUTHOR]

Purpose: Combining high‐resolution magnetic resonance imaging (MRI) with a linear accelerator (Linac) as a single MRI‐Linac system provides the capability to monitor intra‐fractional motion and anatomical changes during radiotherapy, which facilitates more accurate delivery of radiation dose to the tumor and less exposure to healthy tissue. The gradient nonlinearity (GNL)‐induced distortions in MRI, however, hinder the implementation of MRI‐Linac system in image‐guided radiotherapy where highly accurate geometry and anatomy of the target tumor is indispensable. Methods: To correct the geometric distortions in MR images, in particular, for the 1 Tesla (T) MRI‐Linac system, a deep fully connected neural network was proposed to automatically learn the intricate relationship between the undistorted (theoretical) and distorted (real) space. A dataset, consisting of spatial samples acquired by phantom measurement that covers both inside and outside the working diameter of spherical volume (DSV), was utilized for training the neural network, which offers the ability to describe subtle deviations of the GNL field within the entire region of interest (ROI). Results: The performance of the proposed method was evaluated on MR images of a three‐dimensional (3D) phantom and the pelvic region of an adult volunteer scanned in the 1T MRI‐Linac system. The experimental results showed that the severe geometric distortions within the entire ROI had been successfully corrected with an error less than the pixel size. Also, the presented network is highly efficient, which achieved significant improvement in terms of computational efficiency compared to existing methods. Conclusions: The feasibility of the presented deep neural network for characterizing the GNL field deviations in the 1T MRI‐Linac system was demonstrated in this study, which shows promise in facilitating the MRI‐Linac system to be routinely implemented in real‐time MRI‐guided radiotherapy. [ABSTRACT FROM AUTHOR]

Background: The assessment of organ motion is a crucial feature for prostate stereotactic body radiotherapy (SBRT). Rectal spacer may represent a helpful device in order to outdistance rectal wall from clinical target, but its impact on organ motion is still a matter of debate. MRI-Linac is a new frontier in radiation oncology as it allows a superior visualization of the real-time anatomy of the patient and the current highest level of adaptive radiotherapy.Methods: We present data regarding a total of 100 fractions in 20 patients who underwent MRI-guided prostate SBRT for low-to-intermediate risk prostate cancer with or without spacer. Translational and rotational shifts were computed on the pre- and post-treatment MRI acquisitions referring to the delivery position for antero-posterior, latero-lateral and cranio-caudal direction, and assessed using the Mann-Whitney U-Test.Results: All patients were treated with a five sessions schedule (35 Gy/5fx) using MRI-Linac for a median fraction treatment time of 50 min (range, 46-65). In the entire study sample, median rotational displacement was 0.1° in cranio-caudal, - 0.002° in latero-lateral and 0.01° in antero-posterior direction; median translational shift was 0.11 mm in cranio-caudal, - 0.24 mm in latero-lateral and - 0.22 mm in antero-posterior. A significant difference between spacer and no-spacer patients in terms of rotational shifts in the antero-posterior direction (p = 0.033) was observed; also for translational shifts a positive trend was detected in antero-posterior direction (p = 0.07), although with no statistical significance. We observed statistically significant differences in the pre-treatment planning phase in favor of the spacer cohort for several rectum dose constraints: rectum V32Gy < 5% (p = 0.001), V28 Gy < 10% (p = 0.001) and V18Gy < 35% (p = 0.039). Also for bladder V35 Gy < 1 cc, the use of spacer provided a dosimetric advantage compared to the no-spacer subpopulation (p = 0.04). Furthermore, PTV V33.2Gy > 95% was higher in the spacer cohort compared to the no-spacer one (p = 0.036).Conclusion: In our experience, the application of rectal hydrogel spacer for prostate SBRT resulted in a significant impact on rotational antero-posterior shifts contributing to limit prostate intra-fraction motion. Further studies with larger sample size and longer follow-up are required to confirm this ideally favorable effect and to assess any potential impact on clinical outcomes. [ABSTRACT FROM AUTHOR]

Purpose: Dynamic dosimaging is a concept whereby a detector in motion is tracked with magnetic resonance imaging (MRI) to validate the amount and position of dose in a radiation therapy treatment on an MRI‐linac. This work takes steps toward the realization of dynamic dosimaging with the novel high resolution silicon array detector: MagicPlate‐512 (M512). The performance of the M512 was assessed in a 1.0 T inline MRI‐linac, without simultaneous imaging and then during an imaging sequence, both during dosimetry. MR images were acquired to determine the effect of the detector and its components on image quality. Methods: Beam profiles were measured using the M512 on the Australian MRI‐Linac and a comparison made with Gafchromic EBT3 film to investigate any intrinsic magnetic field effects in the silicon. The M512 has 512 sensitive volumes, each 0.5 × 0.5 × 0.037 mm3 in dimension, organized in a two‐dimensional array. Small field sizes up to 4.2 × 3.8 cm2 were investigated in both solid water and then solid lung phantoms. Beam profiles taken at 1.0 T were compared to 0 T conditions, and also to profiles taken during a gradient echo (GRE) imaging sequence. Differences in 80%‐20% penumbral width and full width at half maximum (FWHM) were investigated. Localizer MR images were acquired of the detector adjacent to a water phantom. Results: Good agreement was observed between the M512 and film, with average differences in penumbral width and FWHM of <1 mm in the absence of the imaging sequence. Concurrent imaging widened the penumbra by up to 1.2 mm due to RF noise affecting the detector; film profiles were unchanged. Magnetic resonance images were affected by noise, in particular, due to the large amount of aluminum present, as well as from the USB cable, which acted as an antenna. Unfortunately, due to these issues, suitable dynamic dose imaging was not achieved with the current M512/phantom configuration and the MRI‐linac. However, progress was made toward achieving this goal for future work. Conclusions: The M512 silicon array detector successfully measured high‐resolution beam profiles in agreement with Gafchromic film to within an average of <1 mm on the first MRI‐linac in Australia. More effective noise reduction will be required for the achievement of dynamic dosimaging in the future. [ABSTRACT FROM AUTHOR]

Purpose: The magnetic resonance imaging (MRI)‐Linac system combines a MRI scanner and a linear accelerator (Linac) to realize real‐time localization and adaptive radiotherapy for tumors. Given that the Australian MRI‐Linac system has a 30‐cm diameter of spherical volume (DSV) with a shimmed homogeneity of ±4.05 parts per million (ppm), a gradient nonlinearity (GNL) of <5% can only be assured within 15 cm from the system's isocenter. GNL increases from the isocenter and escalates close to and outside of the edge of the DSV. Gradient nonlinearity can cause large geometric distortions, which may provide inaccurate tumor localization and potentially degrade the radiotherapy treatment. In this study, we aimed to characterize and correct the geometric distortions both inside and outside of the DSV. Methods: On the basis of phantom measurements, an inverse electromagnetic (EM) method was developed to reconstitute the virtual current density distribution that could generate gradient fields. The obtained virtual EM source was capable of characterizing the GNL field both inside and outside of the DSV. With the use of this GNL field information, our recently developed "GNL‐encoding" reconstruction method was applied to correct the distortions implemented in the k‐space domain. Results: Both phantom and in vivo human images were used to validate the proposed method. The results showed that the maximal displacements within an imaging volume of 30 cm × 30 cm × 30 cm after using the fifth‐order spherical harmonic (SH) method and the proposed method were 6.1 ± 0.6 mm and 1.8 ± 0.6 mm, respectively. Compared with the fifth‐order SH‐based method, the new solution decreased the percentage of markers (within an imaging volume of 30 cm × 30 cm × 30 cm) with ≥1.5‐mm distortions from 6.3% to 1.3%, indicating substantially improved geometric accuracy. Conclusions: The experimental results indicated that the proposed method could provide substantially improved geometric accuracy for the region outside of the DSV, when comparing with the fifth‐order SH‐based method. [ABSTRACT FROM AUTHOR]

Purpose: In this work, the fabrication, operation, and evaluation of a probe‐format graphite calorimeter — herein referred to as Aerrow — as an absolute clinical dosimeter of high‐energy photon beams while in the presence of a B = 1.5 T magnetic field is described. Comparable to a cylindrical ionization chamber (IC) in terms of utility and usability, Aerrow has been developed for the purpose of accurately measuring absorbed dose to water in the clinic with a minimum disruption to the existing clinical workflow. To our knowledge, this is the first reported application of graphite calorimetry to magnetic resonance imaging (MRI)‐guided radiotherapy. Methods: Based on a previously numerically optimized and experimentally validated design, an Aerrow prototype capable of isothermal operation was constructed in‐house. Graphite‐to‐water dose conversions as well as magnetic field perturbation factors were calculated using Monte Carlo, while heat transfer and mass impurity corrections and uncertainties were assessed analytically. Reference dose measurements were performed in the absence and presence of a B = 1.5 T magnetic field using Aerrow in the 7 MV FFF photon beam of an Elekta MRI‐linac and were directly compared to the results obtained using two calibrated reference‐class IC types. The feasibility of performing solid phantom‐based dosimetry with Aerrow and the possible influence of clearance gaps is also investigated by performing reference‐type dosimetry measurements for multiple rotational positions of the detector and comparing the results to those obtained in water. Results: In the absence of the B‐field, as well as in the parallel orientation while in the presence of the B‐field, the absorbed dose to water measured using Aerrow was found to agree within combined uncertainties with those derived from TG‐51 using calibrated reference‐class ICs. Statistically significant differences on the order of (2–4)%, however, were observed when measuring absorbed dose to water using the ICs in the perpendicular orientation in the presence of the B‐field. Aerrow had a peak‐to‐peak response of about 0.5% when rotated within the solid phantom regardless of whether the B‐field was present or not. Conclusions: This work describes the successful use of Aerrow as a straightforward means of measuring absolute dose to water for large high‐energy photon fields in the presence of a 1.5 T B‐field to a greater accuracy than currently achievable with ICs. The detector‐phantom air gap does not appear to significantly influence the response of Aerrow in absolute terms, nor does it contribute to its rotational dependence. This work suggests that the accurate use of solid phantoms for absolute point dose measurement is possible with Aerrow. [ABSTRACT FROM AUTHOR]

• Description of intra-fractional motion management workflow in MRI-guided radiotherapy. • Envisioned workflow with both highest dosimetric accuracy and duty cycle efficiency. • Focus on real-time implementation based on artificial intelligence. MRI-guided radiotherapy (MRIgRT) is a highly complex treatment modality, allowing adaptation to anatomical changes occurring from one treatment day to the other (inter-fractional), but also to motion occurring during a treatment fraction (intra-fractional). In this vision paper, we describe the different steps of intra-fractional motion management during MRIgRT, from imaging to beam adaptation, and the solutions currently available both clinically and at a research level. Furthermore, considering the latest developments in the literature, a workflow is foreseen in which motion-induced over- and/or under-dosage is compensated in 3D, with minimal impact to the radiotherapy treatment time. Considering the time constraints of real-time adaptation, a particular focus is put on artificial intelligence (AI) solutions as a fast and accurate alternative to conventional algorithms. [ABSTRACT FROM AUTHOR]

Purpose: Dose deposition measurements for parallel MRI‐linacs have previously only shown comparisons between 0 T and a single available magnetic field. The Australian MRI‐Linac consists of a magnet coupled with a dual energy linear accelerator and a 120 leaf Multi‐Leaf Collimator with the radiation beam parallel to the magnetic field. Two different magnets, with field strengths of 1 and 1.5 T, were used during prototyping. This work aims to characterize the impact of the magnetic field at 1 and 1.5 T on dose deposition, possible by comparing dosimetry measured at both magnetic field strengths to measurements without the magnetic field. Methods: Dose deposition measurements focused on a comparison of beam quality (TPR20/10), PDD, profiles at various depths, surface doses, and field size output factors. Measurements were acquired at 0, 1, and 1.5 T. Beam quality was measured using an ion chamber in solid water at isocenter with appropriate TPR20/10 buildup. PDDs and profiles were acquired via EBT3 film placed in solid water either parallel or perpendicular to the radiation beam. Films at surface were used to determine surface dose. Output factors were measured in solid water using an ion chamber at isocenter with 10 cm solid water buildup. Results: Beam quality was within ±0.5% of the 0 T value for the 1 and 1.5 T magnetic field strengths. PDDs and profiles showed agreement for the three magnetic field strengths at depths beyond 20 mm. Deposited dose increased at shallower depths due to electron focusing. Output factors showed agreement within 1%. Conclusion: Dose deposition at depth for a parallel MRI‐linac was not significantly impacted by either a 1 or 1.5 T magnetic field. PDDs and profiles at shallow depths and surface dose measurements showed significant differences between 0, 1, and 1.5 T due to electron focusing. [ABSTRACT FROM AUTHOR]

Purpose: Reference dosimetry in a strong magnetic field is made more complex due to (a) the change in dose deposition and (b) the change in sensitivity of the detector. Potentially it is also influenced by thin air layers, interfaces between media, relative orientations of field, chamber and radiation, and minor variations in ion chamber stem or electrode construction. The PTW30013 and IBA FC65‐G detectors are waterproof Farmer‐type ion chambers that are suitable for reference dosimetry. The magnetic field correction factors have previously been determined for these chamber types. The aim of this study was to assess the chamber‐to‐chamber variation and determine whether generic chamber type‐specific magnetic field correction factors can be applied for each of the PTW30013 and FC65‐G type ion chambers when they are oriented anti‐parallel (ǁ) to, or perpendicular (⊥) to, the magnetic field. Methods: The experiment was conducted with 12 PTW30013 and 13 FC65‐G chambers. The magnetic field correction factors were measured using a practical method. In this study each chamber was cross‐calibrated against the local standard chamber twice; with and without magnetic field. Measurements with 1.5 T magnetic field were performed with the 7 MV FFF beam of the MRI‐linac. Measurements without magnetic field (0 T) were performed with the 6 MV conventional beam of an Elekta Agility linac. A prototype MR‐compatible PTW MP1 phantom was used along with a prototype holder that facilitated measurements with the chamber aligned 90° counter‐clockwise (⊥) and 180° (ǁ) to the direction of the magnetic field. A monitor chamber was also mounted on the holder and all measurements were normalized so that the effect of variations in the output of each linac was minimized. Measurements with the local standard chamber were repeated during the experiment to quantify the experimental uncertainty. Recombination was measured in the 6 MV beam. Beam quality correction factors were applied. Differences in recombination and beam quality between beams are constant within each chamber type. By comparing the results for the two cross calibrations the magnetic field correction factors can be determined for each chamber, and the variation within the chamber‐type determined. Results: The magnetic field correction factors within both PTW30013 and FC65‐G chamber‐types were found to be very consistent, with observed standard deviations for the PTW30013 of 0.19% (ǁ) and 0.13% (⊥), and for the FC65‐G of 0.15% (ǁ) and 0.17% (⊥). These variations are comparable with the standard uncertainty (k = 1) of 0.24%. Conclusion: The consistency of the results for the PTW30013 and FC65‐G chambers implies that it is not necessary to derive a new factor for every new PTW30013 or FC65‐G chamber. Values for each chamber‐type (with careful attention to beam energy, magnetic field strength and beam‐field‐chamber orientations) can be applied from the literature. [ABSTRACT FROM AUTHOR]

Purpose: This work describes the first live imaging and radiation delivery performed on a prototype 1.0 T inline MRI‐Linac system in a rat brain tumor model, which was conducted on 29 January 2019. Methods: A human scale 1.0 T MRI‐Linac was adapted to be suitable for animal studies via a specially constructed open 6‐channel receiver radiofrequency (RF) coil. A Fischer rat injected with 9L glioma cells in the right hemisphere was imaged and irradiated at day 11 post surgery as part of a larger cohort survival study. The rat was anesthetized and positioned at the iscocenter of the MRI‐Linac. Imaging was used to localize the brain and confirm the presence of a tumor following the administration of a gadolinium nanoparticle contrast agent. A single dose of 10 Gy was delivered using a 2.25 cm × 2.90 cm radiation field covering the whole brain and verified with radiosensitive film in situ. Real‐time imaging was used throughout the irradiation period to monitor the animal and target position. Results: The signal‐to‐noise ratio (SNR) measured in the rat brain was 38. Postcontrast imaging was able to demonstrate a tumor of 5 mm diameter in the upper right hemisphere of the brain approximately 45 min after administration of the nanoparticles. The radiation beam had no impact on SNR and images at the rate of 2 Hz were effective in monitoring both respiration and intrafractional motion. In vivo film dosimetry confirmed the intended dose delivery. The total procedure time was 35 min. Conclusions: We have successfully used MRI guidance to localize and subsequently deliver a radiation field to the whole brain of a rat with a right hemispheric tumor. Real‐time imaging during beam on was of sufficient quality to monitor breathing and perform exception gating of the treatment. This represents the first live use of a high field inline MRI‐Linac. [ABSTRACT FROM AUTHOR]

Purpose: Electronic portal imaging devices (EPIDs) are potentially useful for dosimetric verification in integrated MRI‐linac systems. This work presents the reproducibility, linearity, image lag, and radiation field profiles in a conventional EPID, with and without a 0.5 T parallel magnetic field present in a 6 MV photon beam. Methods: An aS500 EPID was modified to function in strong magnetic fields. All measurements were made using the linac‐MR installed at the Cross Cancer Institute. The EPID remained stationary on the couch between the measurements made with and without magnetic field. We measured short‐term reproducibility of dark and flood fields, signal linearity from 1 to 500 MU irradiations, and image lag post 100 MU irradiation. An ion chamber was used to measure any linac output variations to correct the EPID signal due to these variations for the duration of experiment. X‐axis and Y‐axis radiation field profiles were obtained from the EPID image resulting from a 10 × 10 cm2 radiation field delivery. Results: The average pixel value (±standard deviation) of flood field with and without magnetic fields were 57,876 ± 379 and 57,703 ± 366, respectively, and the corresponding average dark field pixel values were −32.05 ± 0.85 and −32.19 ± 0.97. The maximum difference in image linearity data with and without magnetic field is 0.2% which is well within the measurement uncertainty of 0.65%. Similarly, the image lag curves, with and without the magnetic field, were nearly identical. The first measured point, with mean lag signal of 1.44% without and 1.41% with magnetic field, shows that the largest difference is well below the uncertainty in the EPID signal measurement. The radiation field profiles obtained with and without magnetic fields were nearly identical; 91.3% of the X‐axis and 95.2% of the Y‐axis profile points pass a gamma criterion of 1% and 1 mm. Conclusions: A conventional EPID imager with a 0.1 cm copper plate responds to 6 MV photons similarly irrespective of the strong magnetic field being off or on in the parallel orientation to the radiation beam. Thus, the EPID is a potentially useful tool for pretreatment dosimetric verification in linac‐MR systems using parallel magnetic field. [ABSTRACT FROM AUTHOR]

• Different image post-processing introduces ADC variation between centres. • Aligning ADC calculation methods between centres improves reproducibility. • Calculation-related ADC variation is larger than delineation-related ADC variation. The apparent diffusion coefficient (ADC), a potential imaging biomarker for radiotherapy response, needs to be reproducible before translation into clinical use. The aim of this study was to evaluate the multi-centre delineation- and calculation-related ADC variation and give recommendations to minimize it. Nine centres received identical diffusion-weighted and anatomical magnetic resonance images of different cancerous tumours (adrenal gland, pelvic oligo metastasis, pancreas, and prostate). All centres delineated the gross tumour volume (GTV), clinical target volume (CTV), and viable tumour volume (VTV), and calculated ADCs using both their local calculation methods and each of the following calculation conditions: b-values 0–500 vs. 150–500 s/mm2, region-of-interest (ROI)-based vs. voxel-based calculation, and mean vs. median. ADC variation was assessed using the mean coefficient of variation across delineations (CV D) and calculation methods (CV C). Absolute ADC differences between calculation conditions were evaluated using Friedman's test. Recommendations for ADC calculation were formulated based on observations and discussions within the Elekta MRI-linac consortium image analysis working group. The median (range) CV D and CV C were 0.06 (0.02–0.32) and 0.17 (0.08–0.26), respectively. The ADC estimates differed 18% between b-value sets and 4% between ROI/voxel-based calculation (p-values < 0.01). No significant difference was observed between mean and median (p = 0.64). Aligning calculation conditions between centres reduced CV C to 0.04 (0.01–0.16). CV D was comparable between ROI types. Overall, calculation methods had a larger impact on ADC reproducibility compared to delineation. Based on the results, significant sources of variation were identified, which should be considered when initiating new studies, in particular multi-centre investigations. [ABSTRACT FROM AUTHOR]

Abstract The desire to utilise soft-tissue image guidance at the time of radiation treatment has led to the development of several hybrid magnetic resonance imaging (MRI) linear accelerators (linacs). These systems have the potential to realise the benefits of MRI on the treatment table with the ability of real-time motion management and adaption on a patient-specific basis. There are several MRI-linacs currently being implemented covering both low and high magnetic field strength and two beam-field orientations. Clinical trials have only recently begun with this technology, but their future use as standard radiotherapy practice seems assured. This review article summarises the challenges faced in developing such hybrid technology, the differences and advantages of each of the currently exploited solutions, and their current status. [ABSTRACT FROM AUTHOR]

Purpose: Longitudinal magnetic fields narrow beam penumbra and tighten lateral spread of secondary electrons in air cavities, including lung tissue. Gafchromic® EBT3 film was used to investigate differences between penumbra in solid water and solid lung, without a magnetic field (0 T) and with two field strengths (0.9 and 1.5 T). Methods: The first prototype of the Australian MRI‐linac consisted of a 1.5 T Siemens Sonata MRI and Varian industrial linatron (nominal 4 MV). The second prototype replaced the Sonata with a 1.0 T Agilent split‐bore magnet. Measurements were completed at 0.9 T to maintain the same source‐to‐surface distance between set‐ups. Gammex‐rmi® solid water with 50 mm of CIRS solid lung inserted as a lung cavity was positioned inside each magnet. This was compared to the same set‐up with solid water only, where film measurements were completed at solid water equivalent depths corresponding to entrance interface/mid/exit interface positions of solid lung from the first set‐up. Multileaf collimator (MLC)‐defined field sizes were set to 3 × 3 cm2 and 10 × 10 cm2. The 80%–20% penumbral width was determined. Results: Under 1.5 T conditions, penumbra narrowing occurred up to 4.4 ± 0.1 mm compared to 0 T. As expected, the effect was less for 0.9 T, which resulted in a maximum narrowing of 2.5 ± 0.1 mm. Exit profile penumbra were more affected than entrance penumbra by up to 2.6 ± 0.2 mm. The 1.5 T field brought the solid water and lung penumbral widths more into alignment by a maximum difference of 0.4 ± 0.1 mm. Conclusions: The trimming of penumbral widths due to magnetic fields in solid water and lung was demonstrated and compared to 0 T. The 0.9 and 1.5 T field trimmed the penumbra by up to 2.5 ± 0.1 mm and 4.4 ± 0.1 mm respectively. [ABSTRACT FROM AUTHOR]

The increased utilisation of magnetic resonance imaging ( MRI) in radiation therapy ( RT) has led to the implementation of MRI simulators for RT treatment planning and influenced the development of MRI-guided treatment systems. There is extensive literature on the advantages of MRI for tumour volume and organ-at-risk delineation compared to computed tomography. MRI provides both anatomical and functional information for RT treatment planning ( RTP) as well as quantitative information to assess tumour response for adaptive treatment. Despite many advantages of MRI in RT, introducing an MRI simulator into a RT department is a challenge. Collaboration between radiographers and radiation therapists is paramount in making the best use of this technology. The cross-disciplinary training of radiographers and radiation therapists alike is an area rarely discussed; however, it is becoming an important requirement due to detailed imaging needs for advanced RT treatment techniques and with the emergence of hybrid treatment systems. This article will discuss the initial experiences of a radiation oncology department in implementing a dedicated MRI simulator for RTP, with a focus on the training required for both radiographer and RT staff. It will also address the future of MRI in RT and the implementation of MRI-guided treatment systems, such as MRI-Linacs, and the role of both radiation therapists and radiographers in this technology. [ABSTRACT FROM AUTHOR]

Purpose Conventionally in radiotherapy, a very heavy beam forming apparatus (gantry) is rotated around a patient. From a mechanical perspective, a more elegant approach is to rotate the patient within a stationary beam. Key obstacles to this approach are patient tolerance and anatomical deformation. Very little information on either aspect is available in the literature. The purpose of this work was therefore to design and test an MRI-compatible patient rotation system such that the feasibility of a patient rotation workflow could be tested. Methods A patient rotation system (PRS) was designed to fit inside the bore of a 3T MRI scanner (Skyra, Siemens) such that 3D images could be acquired at different rotation angles. Once constructed, a pelvic imaging study was carried out on a healthy volunteer. T2-weighted MRI images were taken every 45° between 0° and 360°, (with 0° equivalent to supine). The prostate, bladder, and rectum were segmented using atlas-based auto contouring. The images from each angle were registered back to the 0° image in three steps: (a) Rigid registration was based on MRI visible markers on the couch. (b) Rigid registration based on the prostate contour (equivalent to a rigid shift to the prostate). (c) Nonrigid registration. The Dice similarity coefficient (DSC) and mean average surface distance (MASD) were calculated for each organ at each step. Results The PRS met all design constraints and was successfully integrated with the MRI scanner. Phantom images showed minimal difference in signal or noise with or without the PRS in the MRI scanner. For the MRI images, the DSC (mean ± standard deviation) over all angles in the prostate, rectum, and bladder was 0.60 ± 0.11, 0.56 ± 0.15, and 0.76 ± 0.06 after rigid couch registration, 0.88 ± 0.03, 0.81 ± 0.08, and 0.86 ± 0.03 after rigid prostate guided registration, and 0.85 ± 0.03, 0.88 ± 0.02, 0.87 ± 0.02 after nonrigid registration. Conclusions An MRI-compatible patient rotation system has been designed, constructed, and tested. A pelvic study was carried out on a healthy volunteer. Rigid registration based on the prostate contour yielded DSC overlap statistics in the prostate superior to interobserver contouring variability reported in the literature. [ABSTRACT FROM AUTHOR]

Purpose: MRI-linac therapy is a rapidly growing field, and requires that conventional linear accelerators are operated with the fringe field of MRI magnets. One of the most sensitive accelerator components is the electron gun, which serves as the source of the beam. The purpose of this work was to develop a validated finite element model (FEM) model of a clinical triode (or gridded) electron gun, based on accurate geometric and electrical measurements, and to characterize the performance of this gun in magnetic fields. Methods: The geometry of a Varian electron gun was measured using 3D laser scanning and digital calipers. The electric potentials and emission current of these guns were measured directly from six dose matched true beam linacs for the 6X, 10X, and 15X modes of operation. Based on these measurements, a finite element model (FEM) of the gun was developed using the commercial software ?????/?????. The performance of the FEM model in magnetic fields was characterized using parallel fields ranging from 0 to 200 G in the in-line direction, and 0-35 G in the perpendicular direction. Results: The FEM model matched the average measured emission current to within 5% across all three modes of operation. Different high voltage settings are used for the different modes; the 6X, 10X, and 15X modes have an average high voltage setting of 15, 10, and 11 kV. Due to these differences, different operating modes show different sensitivities in magnetic fields. For in line fields, the first current loss occurs at 40, 20, and 30 G for each mode. This is a much greater sensitivity than has previously been observed. For perpendicular fields, first beam loss occurred at 8, 5, and 5 G and total beam loss at 27, 22, and 20 G. Conclusions: A validated FEM model of a clinical triode electron gun has been developed based on accurate geometric and electrical measurements. Three different operating modes were simulated, with a maximum mean error of 5%. This gun shows greater sensitivity to in-line magnetic fields than previously presented models, and different operating modes show different sensitivity. [ABSTRACT FROM AUTHOR]

Purpose: The pursuit of real-time image guided radiotherapy using optimal tissue contrast has seen the development of several hybrid magnetic resonance imaging (MRI)-treatment systems, high field and low field, and inline and perpendicular configurations. As part of a new MRI-linac program, an MRI scanner was integrated with a linear accelerator to enable investigations of a coupled inline MRI-linac system. This work describes results from a prototype experimental system to demonstrate the feasibility of a high field inline MR-linac. Methods: The magnet is a 1.5 T MRI system (Sonata, Siemens Healthcare) was located in a purpose built radiofrequency (RF) cage enabling shielding from and close proximity to a linear accelerator with inline (and future perpendicular) orientation. A portable linear accelerator (Linatron, Varian) was installed together with a multileaf collimator (Millennium, Varian) to provide dynamic field collimation and the whole assembly built onto a stainless-steel rail system. A series of MRI-linac experiments was performed to investigate (1) image quality with beam on measured using a macropodine (kangaroo) ex vivo phantom; (2) the noise as a function of beam state measured using a 6-channel surface coil array; and (3) electron contamination effects measured using Gafchromic film and an electronic portal imaging device (EPID). Results: (1) Image quality was unaffected by the radiation beam with the macropodine phantom image with the beam on being almost identical to the image with the beam off. (2) Noise measured with a surface RF coil produced a 25% elevation of background intensity when the radiation beam was on. (3) Film and EPID measurements demonstrated electron focusing occurring along the centerline of the magnet axis. Conclusions: A proof-of-concept high-field MRI-linac has been built and experimentally characterized. This system has allowed us to establish the efficacy of a high field inline MRI-linac and study a number of the technical challenges and solutions. [ABSTRACT FROM AUTHOR]

An MRI–LINAC system combines a magnetic resonance imaging (MRI) system with a medical linear accelerator (LINAC) to provide image-guided radiotherapy for targeting tumors in real-time. In an MRI–LINAC system, a set of split gradient coils is employed to produce orthogonal gradient fields for spatial signal encoding. Owing to this unconventional gradient configuration, eddy currents induced by switching gradient coils on and off may be of particular concern. It is expected that strong intra-coil interactions in the set will be present due to the constrained return paths, leading to potential degradation of the gradient field linearity and image distortion. In this study, a series of gradient coils with different track widths have been designed and analyzed to investigate the electromagnetic interactions between coils in a split gradient set. A driving current, with frequencies from 100 Hz to 10 kHz, was applied to study the inductive coupling effects with respect to conductor geometry and operating frequency. It was found that the eddy currents induced in the un-energized coils (hereby-referred to as passive coils) positively correlated with track width and frequency. The magnetic field induced by the eddy currents in the passive coils with wide tracks was several times larger than that induced by eddy currents in the cold shield of cryostat. The power loss in the passive coils increased with the track width. Therefore, intra-coil interactions should be included in the coil design and analysis process. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the acoustic noise levels induced by the split-gradient coils of a MRI-LINAC system, and also propose a scheme for acoustic noise reduction. Methods: A finite element (FE) modeling method was used to simulate the acoustic environment of a MRI-LINAC system. By optimizing mounting supports between the split gradient assembly and the main magnet, the authors first altered the vibration modes of the acoustic system, smoothed the acoustic frequency responses, and relocated the acoustic field distribution in the central gap, cylindrical tunnels, and outside of the central gap. The acoustic noise was further reduced by means of applying damping treatment on the surfaces of the split-gradient assembly. Results: Compared with conventional bolts that were placed at the ends, when the near supports were fixed and the far adjustable supports were 40 cm away from the further (here near and far are relative to the central gap) ends of the split-gradient assembly, the overall average sound pressure level (SPL) reductions were about 6.3-9.9 dB both inside and outside the central gap for the transverse and longitudinal coils. After applying damping treatment, the average SPLs inside the central gap and outside it were further reduced by 8.5-12.5 and 6.3-8.8 dB for the transverse coils and longitudinal coils, respectively. Conclusions: The authors' FE results showed that, for the cases of transverse coil and longitudinal coil switching, the overall average-SPL reduction quantities amounted to around 20 dB by applying the proposed noise reduction scheme, resulting in lower SPLs than the human hearing threshold. [ABSTRACT FROM AUTHOR]

Purpose: Magnetic fields are known to alter radiation dose deposition. Before patients receive treatment using an MRI-linear accelerator (MRI-Linac), preclinical studies are needed to understand the biological consequences of magnetic-field-induced dose effects. In the present study, the authors sought to identify a beam energy and magnetic field strength combination suitable for preclinical murine experiments. Methods: Magnetic field dose effects were simulated in a mouse lung phantom using various beam energies (225 kVp, 350 kVp, 662 keV [Cs-137], 2 MV, and 1.25 MeV [Co-60]) and magnetic field strengths (0.75, 1.5, and 3 T). The resulting dose distributions were compared with those in a simulated human lung phantom irradiated with a 6 or 8MVbeam and orthogonal 1.5 T magnetic field. Results: In the human lung phantom, the authors observed a dose increase of 45% and 54% at the soft-tissue-to-lung interface and a dose decrease of 41% and 48% at the lung-to-soft-tissue interface for the 6 and 8 MV beams, respectively. In the mouse simulations, the magnetic fields had no measurable effect on the 225 or 350 kVp dose distribution. The dose increases with the Cs-137 beam for the 0.75, 1.5, and 3 T magnetic fields were 9%, 29%, and 42%, respectively. The dose decreases were 9%, 21%, and 37%. For the 2 MV beam, the dose increases were 16%, 33%, and 31% and the dose decreases were 9%, 19%, and 30%. For the Co-60 beam, the dose increases were 19%, 54%, and 44%, and the dose decreases were 19%, 42%, and 40%. Conclusions: The magnetic field dose effects in the mouse phantom using a Cs-137, 3 T combination or a Co-60, 1.5 or 3 T combination most closely resemble those in simulated human treatments with a 6 MV, 1.5 T MRI-Linac. The effects with a Co-60, 1.5 T combination most closely resemble those in simulated human treatments with an 8 MV, 1.5 T MRI-Linac. [ABSTRACT FROM AUTHOR]

ABSTRACT In some MRI-LINAC (Magnetic Resonance Imaging and Linear Accelerator) hybrid systems, the MRI scanner is split into two parts to form a central gap for the accommodation of the patient or a LINAC. Little is known about the acoustic characteristics of the split gradient coil structure needed for this system; however, it is believed to be very different from its typical configurations. It is important to develop dedicated numerical methods for the characterization of the unique acoustic properties, to provide engineering solutions for the noise attenuation for such a new system. In this article, we modeled the acoustic fields of a split MRI system and traditional gradient structures using the finite element method. The models were validated against acoustic experimental results obtained from a conventional MRI scanner. The acoustic field distribution analysis showed that the average sound pressure levels in the central gap were lower than those in the cylindrical tunnels of the split MRI system at most frequencies. This was also true when both the x coils or z coils were energized independently. Thus, if the patient bed is placed perpendicular to the axis of the main magnet of the split MRI system, the patient will be subjected to relatively lower acoustic intensities compared with that if the patient bed is placed parallel to the axis of the main magnet. Further work is planned to reduce the sound level in the central gap where the patient bed may be placed for this split system. © 2015 Wiley Periodicals, Inc. Concepts Magn Reson Part B (Magn Reson Engineering) 45B: 85-96, 2015 [ABSTRACT FROM AUTHOR]

Purpose: In the framework of developing the integration of a MRI-Linac system, configurations of MRI-Linac units were simulated in order to improve the dose distribution in tangential breast radiotherapy using transverse and longitudinal magnetic field geometries of Lorentz force for both medial and lateral tangential fields. Methods: In this work, the GEANT4 Monte Carlo (MC) code was utilized to compare dose distributions in breast radiotherapy for Linac-MR systems in the transverse and longitudinal geometries within humanoid phantoms across a range of magnetic field strengths of 0.5 and 1.5 T. The dose increment due to scattering from the coils was investigated for both geometries as well. Computed tomography images of two patients were used for MC simulations. One patient had intact breast while the other was mastectomized. In the simulations, planning and methods of chest wall irradiation were similar to the actual clinical planning. Results: In a longitudinal geometry, the magnetic field is shown to restrict the lateral spread of secondary electrons to the lung, heart, and contralateral organs, which reduced the mean dose of the ipsilateral lung and heart by means of 17.2% and 6% at 1.5 T, respectively. The transverse configuration exhibits a significant increase in tissue interface effects, which increased dose buildup in the entrance regions of the lateral and medial tangent beams to the planning target volume (PTV) and improved dose homogeneity within the PTV. The improved relative average homogeneity index for two patients to the PTV at magnetic field strength of 1.5 T with respect to no magnetic field case evaluated was 11.79% and 34.45% in the LRBP and TRBP geometries, respectively. In both geometries, the simulations show significant mean dose reductions in the contralateral breast and chest wall skin, respectively, by a mean of 16.6% and 24.9% at 0.5 T and 17.2% and 28.1% at 1.5 T in the transverse geometry, and 10.56% and 14.6% at 0.5 T and 11.3% and 16.3% at 1.5 T in the longitudinal geometry. Considering the scattered photons which reflected from the coils, the average relative dose of each voxel is slightly increased by 0.53% and 0.32% in the LRBP and TRBP geometries, respectively. Conclusions: Orienting the B0 magnetic field parallel to the photon beam axis, LRBP geometry, tends to restrict the radial spread of secondary electrons which resulted in dose reduction to the lung. Dosimetry issues observed in both Linac-MR geometries, such as changes to the lateral dose distribution, significantly exhibited dose reduction in the contralateral organs on a representative breast plan. Further, the results show sharper edge dose volume histogram curves at 1.5 T for both geometries, especially in the LRBP configuration. [ABSTRACT FROM AUTHOR]

Purpose: MRI-guided radiation therapy systems (MRIgRT) are being developed to improve online imaging during treatment delivery. At present, the operation of single point dosimeters and an ionization chamber array have been characterized in such systems. This work investigates a novel 2D diode array, named "magic plate," for both single point calibration and 2D positional performance, the latter being a key element of modern radiotherapy techniques that will be delivered by these systems. Methods: GEANT4 Monte Carlo methods have been employed to study the dose response of a silicon diode array to 6 MV photon beams, in the presence of in-line and perpendicularly aligned uniform magnetic fields. The array consists of 121 silicon diodes (dimensions 1.5 x 1.5 x 0.38 mm³) embedded in kapton substrate with 1 cm pitch, spanning a 10 x 10 cm² area in total. A geometrically identical, water equivalent volume was simulated concurrently for comparison. The dose response of the silicon diode array was assessed for various photon beam field shapes and sizes, including an IMRT field, at 1 T. The dose response was further investigated at larger magnetic field strengths (1.5 and 3 T) for a 4 x 4 cm² photon field size. Results: The magic plate diode array shows excellent correspondence (< ±1%) to water dose in the in-line orientation, for all beam arrangements and magnetic field strengths investigated. The perpendicular orientation, however, exhibits a dose shift with respect to water at the high-dose-gradient beam edge of jaw-defined fields [maximum (4.3 ± 0.8)% over-response, maximum (1.8 ± 0.8)% under-response on opposing side for 1 T, uncertainty 1σ]. The trend is not evident in areas with in-field dose gradients typical of IMRT dose maps. Conclusions: A novel 121 pixel silicon diode array detector has been characterized by Monte Carlo simulation for its performance inside magnetic fields representative of current prototype and proposed MRI-linear accelerator systems. In the in-line orientation, the silicon dose is directly proportional to the water dose. In the perpendicular orientation, there is a shift in dose response relative to water in the highest dose gradient regions, at the edge of jaw-defined and single-segment MLC fields. The trend was not observed in-field for an IMRT beam. The array is expected to be a valuable tool in MRIgRT dosimetry. [ABSTRACT FROM AUTHOR]

Purpose: Atrial fibrillation (AFib) is the most common cardiac arrhythmia that affects millions of patients world-wide. AFib is usually treated with minimally invasive, time consuming catheter ablation techniques. While recently noninvasive radiosurgery to the pulmonary vein antrum (PVA) in the left atrium has been proposed for AFib treatment, precise target location during treatment is challenging due to complex respiratory and cardiac motion. A MRI linear accelerator (MRI-Linac) could solve the problems of motion tracking and compensation using real-time image guidance. In this study, the authors quantified target motion ranges on cardiac magnetic resonance imaging (MRI) and analyzed the dosimetric benefits of margin reduction assuming real-time motion compensation was applied Methods: For the imaging study, six human subjects underwent real-time cardiac MRI under free breathing. The target motion was analyzed retrospectively using a template matching algorithm. The planning study was conducted on a CT of an AFib patient with a centrally located esophagus undergoing catheter ablation, representing an ideal case for cardiac radiosurgery. The target definition was similar to the ablation lesions at the PVA created during catheter treatment. Safety margins of 0 mm (perfect tracking) to 8 mm (untracked respiratory motion) were added to the target, defining the planning target volume (PTV). For each margin, a 30 Gy single fraction IMRT plan was generated. Additionally, the influence of 1 and 3 T magnetic fields on the treatment beam delivery was simulated using Monte Carlo calculations to determine the dosimetric impact of MRI guidance for two different Linac positions Results: Real-time cardiac MRI showed mean respiratory target motion of 10.2 mm (superior-inferior), 2.4 mm (anterior-posterior), and 2 mm (left-right). The planning study showed that increasing safety margins to encompass untracked respiratory motion leads to overlapping structures even in the ideal scenario, compromising either normal tissue dose constraints or PTV coverage. The magnetic field caused a slight increase in the PTV dose with the in-line MRI-Linac configuration. Conclusions: The authors' results indicate that real-time tracking and motion compensation are mandatory for cardiac radiosurgery and MRI-guidance is feasible, opening the possibility of treating cardiac arrhythmia patients completely noninvasively [ABSTRACT FROM AUTHOR]

Purpose: A potential side effect of inline MRI-linac systems is electron contamination focusing causing a high skin dose. In this work, the authors reexamine this prediction for an open bore 1 T MRI system being constructed for the Australian MRI-Linac Program. The efficiency of an electron contamination deflector (ECD) in purging electron contamination from the linac head is modeled, as well as the impact of a helium gas region between the deflector and phantom surface for lowering the amount of air-generated contamination. Methods: Magnetic modeling of the 1 T MRI was used to generate 3D magnetic field maps both with and without the presence of an ECD located immediately below the MLC's. Forty-seven different ECD designs were modeled and for each the magnetic field map was imported into Geant4 Monte Carlo simulations including the linac head, ECD, and a 30 × 30 × 30 cm3 water phantom located at isocenter. For the first generation system, the x-ray source to isocenter distance (SID) will be 160 cm, resulting in an 81.2 cm long air gap from the base of the ECD to the phantom surface. The first 71.2 cm was modeled as air or helium gas, with the latter encased between two windows of 50 μm thick high density polyethlyene. 2D skin doses (at 70 μm depth) were calculated across the phantom surface at 1 × 1 mm² resolution for 6 MV beams of field size of 5 × 5, 10 × 10, and 20 × 20 cm². Results: The skin dose was predicted to be of similar magnitude as the generic systems modeled in previous work, 230% to 1400% of Dmax for 5 × 5 to 20 × 20 cm², respectively. Inclusion of the ECD introduced a nonuniformity to the MRI imaging field that ranged from ~20 to ~140 ppm while the net force acting on the ECD ranged from ~151 N to ~1773 N. Various ECD designs were 100% efficient at purging the electron contamination into the ECD magnet banks; however, a small percentage were scattered back into the beam and continued to the phantom surface. Replacing a large portion of the extended air-column between the ECD and phantom surface with helium gas is a key element as it significantly minimized the air-generated contamination. When using an optimal ECD and helium gas region, the 70 μm skin dose is predicted to increase moderately inside a small hot spot over that of the case with no magnetic field present for the jaw defined square beams examined here. These increases include from 12% to 40% of Dmax for 5 × 5 cm², 18% to 55% of Dmax for 10 × 10 cm², and from 23% to 65% of Dmax for 20 × 20 cm². Conclusions: Coupling an efficient ECD and helium gas region below the MLCs in the 160 cm isocenter MRI-linac system is predicted to ameliorate the impact electron contamination focusing has on skin dose increases. An ECD is practical as its impact on the MRI imaging distortion is correctable, and the mechanical forces acting on it manageable from an engineering point of view. [ABSTRACT FROM AUTHOR]

MRI-LINAC is a new image-guided radiotherapy treatment system that combines magnetic resonance imaging (MRI) and a linear particle accelerator (LINAC) into a single unit. Moving (i.e., rotating or translating) the patient inside the strong magnetic field of the split MRI-LINAC magnet can potentially induce high levels of electric fields and corresponding current densities in the conducting tissues. The prediction and assessment of patient safety in terms of electromagnetic field exposure have received very little attention for a split cylindrical MRI magnet configuration, especially in the vicinity of the gap region. In this novel numerical study, based on the quasi-static finite-difference method, rotation-induced electric fields and current densities are calculated considering a split 1-T magnet and a tissue-accurate 2-mm-resolution human body model. The patient was modeled in both axial and radial orientations relative to the magnet gap in a number of treatment/imaging scenarios. It was found that rotating the patient in the radial orientation produced an order of magnitude larger field exposure in the central nervous system than when the patient was rotated in the axial orientation. Also, rotating the patient with periods lower than about Trot = 43.3 s may result in field exposures above the limits set out in the international safety guidelines. The novel results of this investigation can provide useful insights into the safe use of the MRI-LINAC technology and optimal orientations of the patient during the treatment. [ABSTRACT FROM PUBLISHER]

Purpose: This work introduces a new electron gun geometry capable of robust functioning in the presence of a high strength external magnetic field for axisymmetric magnetic resonance imaging (MRI)-linac configurations. This allows an inline MRI-linac to operate without the need to isolate the linear accelerator (linac) using a magnetic shield. This MRI-linac integration approach not only leaves the magnet homogeneity unchanged but also provides the linac flexibility to move along the magnet axis of symmetry if the source to target distance needs to be adjusted. Methods: Simple electron gun geometry modifications of a Varian 600C electron gun are considered and solved in the presence of an external magnetic field in order to determine a set of design principles for the new geometry. Based on these results, a new gun geometry is proposed and optimized in the fringe field of a 0.5 T open bore MRI magnet (GE Signa SP). A computer model for the 6 MeV Varian 600C linac is used to determine the capture efficiency of the new electron gun-linac system in the presence of the fringe field of the same MRI scanner. The behavior of the new electron gun plus the linac system is also studied in the fringe fields of two other magnets, a 1.0 T prototype open bore magnet and a 1.5 T GE Conquest scanner. Results: Simple geometrical modifications of the original electron gun geometry do not provide feasible solutions. However, these tests show that a smaller transverse cathode diameter with a flat surface and a slightly larger anode diameter could alleviate the current loss due to beam interactions with the anode in the presence of magnetic fields. Based on these findings, an initial geometry resembling a parallel plate capacitor with a hole in the anode is proposed. The optimization procedure finds a cathode-anode distance of 5 mm, a focusing electrode angle of 5°, and an anode drift tube length of 17.1 mm. Also, the linac can be displaced with ±15 cm along the axis of the 0.5 T magnet without capture efficiency reduction below the experimental value in zero field. In this range of linac displacements, the electron beam generated by the new gun geometry is more effectively injected into the linac in the presence of an external magnetic field, resulting in approximately 20% increase of the target current compared to the original gun geometry behavior at zero field. The new gun geometry can generate and accelerate electron beams in external magnetic fields without current loss for fields higher than 0.11 T. The new electron-gun geometry is robust enough to function in the fringe fields of the other two magnets with a target current loss of no more than 16% with respect to the current obtained with no external magnetic fields. Conclusions: In this work, a specially designed electron gun was presented which can operate in the presence of axisymmetric strong magnetic fringe fields of MRI magnets. Computer simulations show that the electron gun can produce high quality beams which can be injected into a straight through linac such as Varian 600C and accelerated with more efficiency in the presence of the external magnetic fields. Also, the new configuration allows linac displacements along the magnet axis in a range equal to the diameter of the imaging spherical volume of the magnet under consideration. The new electron gun-linac system can function in the fringe field of a MRI magnet if the field strength at the cathode position is higher than 0.11 T. The capture efficiency of the linac depends on the magnetic field strength and the field gradient. The higher the gradient the better the capture efficiency. The capture efficiency does not degrade more than 16%. [ABSTRACT FROM AUTHOR]

A current concern with 6 MV transverse field MRI-linac hybrid systems is the predicted increases in skin dose (both the entry and exit sides) caused by the effects of the magnetic field on secondary electrons. In this work high resolution GEANT4 Monte Carlo simulations have been performed at the beam central axis in the entry and exit regions of a water phantom to predict surface (0 μm depth) and skin (70 μm depth) doses when placed in such a hybrid system. A 30×30×20 cm3 water phantom with 10 μm thick voxels has been simulated by being irradiated perpendicularly with a 6 MV photon beam (Varian 2100C) of sizes of 5×5, 10×10, 15×15, and 20×20 cm2. Uniform transverse magnetic fields of 0.2, 0.75, 1.5, and 3 T with varying thickness above the phantom have been investigated. Simulations with and without lepton contamination have been performed. In the entry region the high resolution scoring has yielded unexpected surface and skin doses. There is a small amount of nonpurged air-generated lepton contamination that originates immediately above the phantom surface and delivers its dose over very short longitudinal distances in the entry region. At 0.2 T the surface and skin doses are not accurately predicted using lepton-contamination-free simulations and extrapolated lower resolution scoring. Lepton-free simulations are up to 7% of Dmax lower than simulations with leptons. However, compared to 0 T, entry skin dose is reduced at 0.2 and 0.75 T but increases to 28%–31% of Dmax at 3 T. For skin doses at the central axis in the exit region, high resolution scoring shows relative increases of 38%–106%, depending on the magnetic field strength and field size. These values are also up to 20% higher than lower resolution results. The shape of the exit dose profiles varies unpredictably and so extrapolation of low resolution data is insufficient. In order to achieve accurate Monte Carlo skin dosimetry in a transverse field MRI-linac system, the authors recommend using high resolution scoring. In systems of 0.2 T the inclusion of air-generated lepton contamination is also recommended. [ABSTRACT FROM AUTHOR]

A novel geometry has been proposed for a hybrid magnetic resonance imaging (MRI)-linac system in which a 6 MV linac is mounted on the open end of a biplanar, low field (0.2 T) MRI magnet on a single gantry that is free to rotate around the patient. This geometry creates a scenario in which the magnetic field vector remains fixed with respect to the incident photon beam, but moves with respect to the patient as the gantry rotates. Other proposed geometries are characterized by a radiation source rotating about a fixed cylindrical magnet where the magnetic field vector remains fixed with respect to the patient. In this investigation we simulate the inherent dose distribution patterns within the two MRI-radiation source geometries using PENELOPE and EGSnrc Monte Carlo radiation transport codes with algorithms implemented to account for the magnetic field deflection of charged particles. Simulations are performed in phantoms and for clinically realistic situations. The novel geometry results in a net Lorentz force that remains fixed with respect to the patient (in the cranial-caudal direction) and results in a cumulative influence on dose distribution for a multiple beam treatment scenario. For a case where patient anatomy is reasonably homogeneous (brain plan), differences in dose compared to a conventional (no magnetic field) case are minimal for the novel geometry. In the case of a lung plan where the inhomogeneous patient anatomy allows for the magnetic field to have significant influence on charged particle transport, larger differences occur in a predictable manner. For a system using a fixed cylindrical geometry and higher magnetic field (1.5 T), differences from the case without a magnetic field are significantly greater. [ABSTRACT FROM AUTHOR]

Simple Summary: During radiotherapy of head and neck cancer patients, the radiation dose for the major salivary glands (parotids and submandibular glands) should be kept as low as possible to reduce toxicity risks. Nevertheless, volume changes and positional shifts of salivary glands during treatment may result in an increased dose, so adapting the treatment plan is recommended. While previous studies primarily used one or two CTs or CBCTs for imaging during treatment, frequent MRI allows for improved soft tissue contrast and more exact contour adaptation without an additional imaging dose. In this study, twelve patients were treated with MRI-guided radiotherapy with weekly offline adaptations. Significant parotid- and submandibular gland shrinkage, as well as a medial shift of the parotids, were observed. These results support the rationale of MR-guided radiotherapy for head and neck cancer, emphasizing the relevance of future clinical evaluation of toxicity to optimize the benefits of MRI-guided radiotherapy. The aim of this study was to quantify anatomical changes of parotids and submandibular glands and evaluate potential dosimetric advantages during weekly adaptive MR-guided radiotherapy (MRgRT) for the definitive treatment of head and neck cancer (HNC). The data and plans of 12 patients treated with bilateral intensity-modulated radiotherapy for HNC using MR-linac, with weekly offline adaptations, were prospectively evaluated. The positional and volumetric changes of the salivary glands were analyzed by manual segmentation in weekly MRI images and the dosimetric impact of these anatomical changes on the adapted treatment plans was assessed. The mean volume change in parotid and submandibular gland volume was −31.9% (p < 0.0001) and −29.7% (p < 0.0001) after five weeks, respectively. The volume change was significantly correlated with the cumulative dose for the respective gland at the time of volume measurement. Inter-parotid distance changed by −5.4% (6.5 mm) on average after five weeks (p = 0.0005). The distance became significantly smaller only in the left-right direction. The inter-submandibular gland distance changed by 0.7 mm (p = 0.38). This study demonstrated significant changes in salivary gland volumes and position following daily MR guidance and weekly plan adaptation. Ongoing clinical trials will provide data on the clinical impact of these changes and novel MR-based adaptation strategies. [ABSTRACT FROM AUTHOR]

The implementation of the radiation oncology alternative payment model (RO-APM) has raised concerns regarding the development of MRI-guided adaptive radiotherapy (MRgART). We sought to compare technical fee reimbursement under Fee-For-Service (FFS) to the proposed RO-APM for a typical MRI-Linac (MRL) patient load and distribution of 200 patients. In an exploratory aim, a modifier was added to the RO-APM (mRO-APM) to account for the resources necessary to provide this care. Traditional Medicare FFS reimbursement rates were compared to the diagnosis-based reimbursement in the RO-APM. Reimbursement for all selected diagnoses were lower in the RO-APM compared to FFS, with the largest differences in the adaptive treatments for lung cancer (−89%) and pancreatic cancer (−83%). The total annual reimbursement discrepancy amounted to −78%. Without implementation of adaptive replanning there was no difference in reimbursement in breast, colorectal and prostate cancer between RO-APM and mRO-APM. Accommodating online adaptive treatments in the mRO-APM would result in a reimbursement difference from the FFS model of −47% for lung cancer and −46% for pancreatic cancer, mitigating the overall annual reimbursement difference to −54%. Even with adjustment, the implementation of MRgART as a new treatment strategy is susceptible under the RO-APM. [ABSTRACT FROM AUTHOR]