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Background: Cardiac applications in radiation therapy are rapidly expanding including magnetic resonance guided radiation therapy (MRgRT) for real‐time gating for targeting and avoidance near the heart or treating ventricular tachycardia (VT). Purpose: This work describes the development and implementation of a novel multi‐modality and magnetic resonance (MR)‐compatible cardiac phantom. Methods: The patient‐informed 3D model was derived from manual contouring of a contrast‐enhanced Coronary Computed Tomography Angiography scan, exported as a Stereolithography model, then post‐processed to simulate female heart with an average volume. The model was 3D‐printed using Elastic50A to provide MR contrast to water background. Two rigid acrylic modules containing cardiac structures were designed and assembled, retrofitting to an MR‐safe programmable motor to supply cardiac and respiratory motion in superior‐inferior directions. One module contained a cavity for an ion chamber (IC), and the other was equipped with multiple interchangeable cavities for plastic scintillation detectors (PSDs). Images were acquired on a 0.35 T MR‐linac for validation of phantom geometry, motion, and simulated online treatment planning and delivery. Three motion profiles were prescribed: patient‐derived cardiac (sine waveform, 4.3 mm peak‐to‐peak, 60 beats/min), respiratory (cos4 waveform, 30 mm peak‐to‐peak, 12 breaths/min), and a superposition of cardiac (sine waveform, 4 mm peak‐to‐peak, 70 beats/min) and respiratory (cos4 waveform, 24 mm peak‐to‐peak, 12 breaths/min). The amplitude of the motion profiles was evaluated from sagittal cine images at eight frames/s with a resolution of 2.4 mm × 2.4 mm. Gated dosimetry experiments were performed using the two module configurations for calculating dose relative to stationary. A CT‐based VT treatment plan was delivered twice under cone‐beam CT guidance and cumulative stationary doses to multi‐point PSDs were evaluated. Results: No artifacts were observed on any images acquired during phantom operation. Phantom excursions measured 49.3 ± 25.8%/66.9 ± 14.0%, 97.0 ± 2.2%/96.4 ± 1.7%, and 90.4 ± 4.8%/89.3 ± 3.5% of prescription for cardiac, respiratory, and cardio‐respiratory motion profiles for the 2‐chamber (PSD) and 12‐substructure (IC) phantom modules respectively. In the gated experiments, the cumulative dose was <2% from expected using the IC module. Real‐time dose measured for the PSDs at 10 Hz acquisition rate demonstrated the ability to detect the dosimetric consequences of cardiac, respiratory, and cardio‐respiratory motion when sampling of different locations during a single delivery, and the stability of our phantom dosimetric results over repeated cycles for the high dose and high gradient regions. For the VT delivery, high dose PSD was <1% from expected (5–6 cGy deviation of 5.9 Gy/fraction) and high gradient/low dose regions had deviations <3.6% (6.3 cGy less than expected 1.73 Gy/fraction). Conclusions: A novel multi‐modality modular heart phantom was designed, constructed, and used for gated radiotherapy experiments on a 0.35 T MR‐linac. Our phantom was capable of mimicking cardiac, cardio‐respiratory, and respiratory motion while performing dosimetric evaluations of gated procedures using IC and PSD configurations. Time‐resolved PSDs with small sensitive volumes appear promising for low‐amplitude/high‐frequency motion and multi‐point data acquisition for advanced dosimetric capabilities. Illustrating VT planning and delivery further expands our phantom to address the unmet needs of cardiac applications in radiotherapy. [ABSTRACT FROM AUTHOR]

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]

Purpose: T1 mapping is a widely used quantitative MRI technique, but its tissue‐specific values remain inconsistent across protocols, sites, and vendors. The ISMRM Reproducible Research and Quantitative MR study groups jointly launched a challenge to assess the reproducibility of a well‐established inversion‐recovery T1 mapping technique, using acquisition details from a seminal T1 mapping paper on a standardized phantom and in human brains. Methods: The challenge used the acquisition protocol from Barral et al. (2010). Researchers collected T1 mapping data on the ISMRM/NIST phantom and/or in human brains. Data submission, pipeline development, and analysis were conducted using open‐source platforms. Intersubmission and intrasubmission comparisons were performed. Results: Eighteen submissions (39 phantom and 56 human datasets) on scanners by three MRI vendors were collected at 3 T (except one, at 0.35 T). The mean coefficient of variation was 6.1% for intersubmission phantom measurements, and 2.9% for intrasubmission measurements. For humans, the intersubmission/intrasubmission coefficient of variation was 5.9/3.2% in the genu and 16/6.9% in the cortex. An interactive dashboard for data visualization was also developed: https://rrsg2020.dashboards.neurolibre.org. Conclusion: The T1 intersubmission variability was twice as high as the intrasubmission variability in both phantoms and human brains, indicating that the acquisition details in the original paper were insufficient to reproduce a quantitative MRI protocol. This study reports the inherent uncertainty in T1 measures across independent research groups, bringing us one step closer to a practical clinical baseline of T1 variations in vivo. [ABSTRACT FROM AUTHOR]

Use of magnetic resonance (MR) imaging in radiation therapy has increased substantially in recent years as more radiotherapy centers are having MR simulators installed, requesting more time on clinical diagnostic MR systems, or even treating with combination MR linear accelerator (MR‐linac) systems. With this increased use, to ensure the most accurate integration of images into radiotherapy (RT), RT immobilization devices and accessories must be able to be used safely in the MR environment and produce minimal perturbations. The determination of the safety profile and considerations often falls to the medical physicist or other support staff members who at a minimum should be a Level 2 personnel as per the ACR. The purpose of this guidance document will be to help guide the user in making determinations on MR Safety labeling (i.e., MR Safe, Conditional, or Unsafe) including standard testing, and verification of image quality, when using RT immobilization devices and accessories in an MR environment. [ABSTRACT FROM AUTHOR]

Background: The static magnetic field present in magnetic resonance (MR)‐guided radiotherapy systems can influence dose deposition and charged particle collection in air‐filled ionization chambers. Thus, accurately quantifying the effect of the magnetic field on ionization chamber response is critical for output calibration. Formalisms for reference dosimetry in a magnetic field have been proposed, whereby a magnetic field quality conversion factor kB,Q is defined to account for the combined effects of the magnetic field on the radiation detector. Determination of kB,Q in the literature has focused on Monte Carlo simulation studies, with experimental validation limited to only a few ionization chamber models. Purpose: The purpose of this study is to experimentally measure kB,Q for 11 ionization chamber models in two commercially available MR‐guided radiotherapy systems: Elekta Unity and ViewRay MRIdian. Methods: Eleven ionization chamber models were characterized in this study: Exradin A12, A12S, A28, and A26, PTW T31010, T31021, and T31022, and IBA FC23‐C, CC25, CC13, and CC08. The experimental method to measure kB,Q utilized cross‐calibration against a reference Exradin A1SL chamber. Absorbed dose to water was measured for the reference A1SL chamber positioned parallel to the magnetic field with its centroid placed at the machine isocenter at a depth of 10 cm in water for a 10 × 10 cm2 field size at that depth. Output was subsequently measured with the test chamber at the same point of measurement. kB,Q for the test chamber was computed as the ratio of reference dose to test chamber output, with this procedure repeated for each chamber in each MR‐guided radiotherapy system. For the high‐field 1.5 T Elekta Unity system, the dependence of kB,Q on the chamber orientation relative to the magnetic field was quantified by rotating the chamber about the machine isocenter. Results: Measured kB,Q values for our test dataset of ionization chamber models ranged from 0.991 to 1.002, and 0.995 to 1.004 for the Elekta Unity and ViewRay MRIdian, respectively, with kB,Q tending to increase as the chamber sensitive volume increased. Measured kB,Q values largely agreed within uncertainty to published Monte Carlo simulation data and available experimental data. kB,Q deviation from unity was minimized for ionization chamber orientation parallel or antiparallel to the magnetic field, with increased deviations observed at perpendicular orientations. Overall (k = 1) uncertainty in the experimental determination of the magnetic field quality conversion factor, kB,Q was 0.71% and 0.72% for the Elekta Unity and ViewRay MRIdian systems, respectively. Conclusions: For a high‐field MR‐linac, the characterization of ionization chamber performance as angular orientation varied relative to the magnetic field confirmed that the ideal orientation for output calibration is parallel. For most of these chamber models, this study represents the first experimental characterization of chamber performance in clinical MR‐linac beams. This is a critical step toward accurate output calibration for MR‐guided radiotherapy systems and the measured kB,Q values will be an important reference data source for forthcoming MR‐linac reference dosimetry protocols. [ABSTRACT FROM AUTHOR]

Background: Pulsed reduced dose rate (PRDR) is an emerging radiotherapy technique for recurrent diseases. It is pertinent that the linac beam characteristics are evaluated for PRDR dose rates and a suitable dosimeter is employed for IMRT QA. Purpose: This study sought to investigate the pulse characteristics of a 6 MV photon beam during PRDR irradiations on a commercial linac. The feasibility of using EBT3 radiochromic film for use in IMRT QA was also investigated by comparing its response to a commercial diode array phantom. Methods: A plastic scintillator detector was employed to measure the photon pulse characteristics across nominal repetition rates (NRRs) in the 5–600 MU/min range. Film was irradiated with dose rates in the 0.033–4 Gy/min range to study the dose rate dependence. Five clinical PRDR treatment plans were selected for IMRT QA with the Delta4 phantom and EBT3 film sheets. The planned and measured dose were compared using gamma analysis with a criterion of 3%/3 mm. EBT3 film QA was performed using a cumulative technique and a weighting factor technique. Results: Negligible differences were observed in the pulse width and height data between the investigated NRRs. The pulse width was measured to be 3.15 ± 0.01 μs$\mu s$ and the PRF was calculated to be 3–357 Hz for the 5–600 MU/min NRRs. The EBT3 film was found to be dose rate independent within 3%. The gamma pass rates (GPRs) were above 99% and 90% for the Delta4 phantom and the EBT3 film using the cumulative QA method, respectively. GPRs as low as 80% were noted for the weighting factor EBT3 QA method. Conclusions: Altering the NRRs changes the mean dose rate while the instantaneous dose rate remains constant. The EBT3 film was found to be suitable for PRDR dosimetry and IMRT QA with minimal dose rate dependence. [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 reduce scan time, methods to accelerate phase‐encoded/non‐Cartesian MR fingerprinting (MRF) acquisitions for variable density spiral acquisitions have recently been developed. These methods are not applicable to MRF acquisitions, wherein a single k‐space spoke is acquired per frame. Therefore, we propose a low‐rank inversion method to resolve MRF contrast dynamics from through‐plane accelerated Cartesian/radial measurements applied to quantitative relaxation‐time mapping on a 0.35T system. Methods: An algorithm was implemented to reconstruct through‐plane aliased low‐rank images describing the contrast dynamics occurring because of the transient‐state MRF acquisition. T1 and T2 times from accelerated acquisitions were compared with those from unaccelerated linear reconstructions in a standardized system phantom and within in vivo brain and prostate experiments on a hybrid 0.35T MRI/linear accelerator. Results: No significant differences between T1 and T2 times for the accelerated reconstructions were observed compared to fully sampled acquisitions (p = 0.41 and p = 0.36, respectively). The mean absolute errors in T1 and T2 were 5.6% and 2.9%, respectively, between the full and accelerated acquisitions. The SDs in T1 and T2 decreased with the advanced accelerated reconstruction compared with the unaccelerated reconstruction (p = 0.02 and p = 0.03, respectively). The quality of the T1 and T2 maps generated with the proposed approach are comparable to those obtained using the unaccelerated data sets. Conclusions: Through‐plane accelerated MRF with radial k‐space coverage was demonstrated at a low field strength of 0.35 T. This method enabled 3D T1 and T2 mapping at 0.35 T with a 3‐min scan. [ABSTRACT FROM AUTHOR]

Radiation therapy (RT) continues to play an important role in the treatment of cancer. Adaptive RT (ART) is a novel method through which RT treatments are evolving. With the ART approach, computed tomography or magnetic resonance (MR) images are obtained as part of the treatment delivery process. This enables the adaptation of the irradiated volume to account for changes in organ and/or tumor position, movement, size, or shape that may occur over the course of treatment. The advantages and challenges of ART maybe somewhat abstract to oncologists and clinicians outside of the specialty of radiation oncology. ART is positioned to affect many different types of cancer. There is a wide spectrum of hypothesized benefits, from small toxicity improvements to meaningful gains in overall survival. The use and application of this novel technology should be understood by the oncologic community at large, such that it can be appropriately contextualized within the landscape of cancer therapies. Likewise, the need to test these advances is pressing. MR‐guided ART (MRgART) is an emerging, extended modality of ART that expands upon and further advances the capabilities of ART. MRgART presents unique opportunities to iteratively improve adaptive image guidance. However, although the MRgART adaptive process advances ART to previously unattained levels, it can be more expensive, time‐consuming, and complex. In this review, the authors present an overview for clinicians describing the process of ART and specifically MRgART. [ABSTRACT FROM AUTHOR]

Byline: Hualiang. Zhong, Jeffrey. Adams, Carri. Glide-Hurst, Hualin. Zhang, Haisen. Li, Indrin. Chetty Adaptive radiotherapy may improve treatment outcomes for lung cancer patients. Because of the lack of an effective [...]

Purpose: The acquisition of multiparametric quantitative magnetic resonance imaging (qMRI) is becoming increasingly important for functional characterization of cancer prior to‐ and throughout the course of radiation therapy. The feasibility of a qMRI method known as magnetic resonance fingerprinting (MRF) for rapid T1 and T2 mapping was assessed on a low‐field MR‐linac system. Methods: A three‐dimensional MRF sequence was implemented on a 0.35T MR‐guided radiotherapy system. MRF‐derived measurements of T1 and T2 were compared to those obtained with gold standard single spin echo methods, and the impacts of the radiofrequency field homogeneity and scan times ranging between 6 and 48 min were analyzed by acquiring between 1 and 8 spokes per time point in a standard quantitative system phantom. The short‐term repeatability of MRF was assessed over three measurements taken over a 10‐h period. To evaluate transferability, MRF measurements were acquired on two additional MR‐guided radiotherapy systems. Preliminary human volunteer studies were performed. Results: The phantom benchmarking studies showed that MRF is capable of mapping T1 and T2 values within 8% and 10% of gold standard measures, respectively, at 0.35T. The coefficient of variation of T1 and T2 estimates over three repeated scans was < 5% over a broad range of relaxation times. The T1 and T2 times derived using a single‐spoke MRF acquisition across three scanners were near unity and mean percent errors in T1 and T2 estimates using the same phantom were < 3%. The mean percent differences in T1 and T2 as a result of truncating the scan time to 6 min over the large range of relaxation times in the system phantom were 0.65% and 4.05%, respectively. Conclusions: The technical feasibility and accuracy of MRF on a low‐field MR‐guided radiation therapy device has been demonstrated. MRF can be used to measure accurate T1 and T2 maps in three dimensions from a brief 6‐min scan, offering strong potential for efficient and reproducible qMRI for future clinical trials in functional plan adaptation and tumor/normal tissue response assessment. [ABSTRACT FROM AUTHOR]

The past decade has seen the increasing integration of magnetic resonance (MR) imaging into radiation therapy (RT). This growth can be contributed to multiple factors, including hardware and software advances that have allowed the acquisition of high‐resolution volumetric data of RT patients in their treatment position (also known as MR simulation) and the development of methods to image and quantify tissue function and response to therapy. More recently, the advent of MR‐guided radiation therapy (MRgRT) ‐ achieved through the integration of MR imaging systems and linear accelerators ‐ has further accelerated this trend. As MR imaging in RT techniques and technologies, such as MRgRT, gain regulatory approval worldwide, these systems will begin to propagate beyond tertiary care academic medical centers and into more community‐based health systems and hospitals, creating new opportunities to provide advanced treatment options to a broader patient population. Accompanying these opportunities are unique challenges related to their adaptation, adoption, and use including modification of hardware and software to meet the unique and distinct demands of MR imaging in RT, the need for standardization of imaging techniques and protocols, education of the broader RT community (particularly in regards to MR safety) as well as the need to continue and support research, and development in this space. In response to this, an ad hoc committee of the American Association of Physicists in Medicine (AAPM) was formed to identify the unmet needs, roadblocks, and opportunities within this space. The purpose of this document is to report on the major findings and recommendations identified. Importantly, the provided recommendations represent the consensus opinions of the committee's membership, which were submitted in the committee's report to the AAPM Board of Directors. In addition, AAPM ad hoc committee reports differ from AAPM task group reports in that ad hoc committee reports are neither reviewed nor ultimately approved by the committee's parent groups, including at the council and executive committee level. Thus, the recommendations given in this summary should not be construed as being endorsed by or official recommendations from the AAPM. [ABSTRACT FROM AUTHOR]

The use of dedicated magnetic resonance simulation (MR‐SIM) platforms in Radiation Oncology has expanded rapidly, introducing new equipment and functionality with the overall goal of improving the accuracy of radiation treatment planning. However, this emerging technology presents a new set of challenges that need to be addressed for safe and effective MR‐SIM implementation. The major objectives of this report are to provide recommendations for commercially available MR simulators, including initial equipment selection, siting, acceptance testing, quality assurance, optimization of dedicated radiation therapy specific MR‐SIM workflows, patient‐specific considerations, safety, and staffing. Major contributions include guidance on motion and distortion management as well as MRI coil configurations to accommodate patients immobilized in the treatment position. Examples of optimized protocols and checklists for QA programs are provided. While the recommendations provided here are minimum requirements, emerging areas and unmet needs are also highlighted for future development. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the dosimetric and image‐guided radiation therapy (IGRT) performance of a novel generative adversarial network (GAN) generated synthetic CT (synCT) in the brain and compare its performance for clinical use including conventional brain radiotherapy, cranial stereotactic radiosurgery (SRS), planar, and volumetric IGRT. Methods and Materials: SynCT images for 12 brain cancer patients (6 SRS, 6 conventional) were generated from T1‐weighted postgadolinium magnetic resonance (MR) images by applying a GAN model with a residual network (ResNet) generator and a convolutional neural network (CNN) with 5 convolutional layers as the discriminator that classified input images as real or synthetic. Following rigid registration, clinical structures and treatment plans derived from simulation CT (simCT) images were transferred to synCTs. Dose was recalculated for 15 simCT/synCT plan pairs using fixed monitor units. Two‐dimensional (2D) gamma analysis (2%/2 mm, 1%/1 mm) was performed to compare dose distributions at isocenter. Dose–volume histogram (DVH) metrics (D95%, D99%, D0.2cc, and D0.035cc) were assessed for the targets and organ at risks (OARs). IGRT performance was evaluated via volumetric registration between cone beam CT (CBCT) to synCT/simCT and planar registration between KV images to synCT/simCT digital reconstructed radiographs (DRRs). Results: Average gamma passing rates at 1%/1mm and 2%/2mm were 99.0 ± 1.5% and 99.9 ± 0.2%, respectively. Excellent agreement in DVH metrics was observed (mean difference ≤0.10 ± 0.04 Gy for targets, 0.13 ± 0.04 Gy for OARs). The population averaged mean difference in CBCT‐synCT registrations were <0.2 mm and 0.1 degree different from simCT‐based registrations. The mean difference between kV‐synCT DRR and kV‐simCT DRR registrations was <0.5 mm with no statistically significant differences observed (P > 0.05). An outlier with a large resection cavity exhibited the worst‐case scenario. Conclusion: Brain GAN synCTs demonstrated excellent performance for dosimetric and IGRT endpoints, offering potential use in high precision brain cancer therapy. [ABSTRACT FROM AUTHOR]

Purpose: Rising evidence suggests that cardiac substructures are highly radiosensitive. However, they are not routinely considered in treatment planning as they are not readily visualized on treatment planning CTs (TPCTs). This work integrated the soft tissue contrast provided by low‐field MRIs acquired on an MR‐linac via image registration to further enable cardiac substructure sparing on TPCTs. Methods: Sixteen upper thoracic patients treated at various breathing states (7 end‐exhalation, 7 end‐inhalation, 2 free‐breathing) on a 0.35T MR‐linac were retrospectively evaluated. A hybrid MR/CT atlas and a deep learning three‐dimensional (3D) U‐Net propagated 13 substructures to TPCTs. Radiation oncologists revised contours using registered MRIs. Clinical treatment plans were re‐optimized and evaluated for beam arrangement modifications to reduce substructure doses. Dosimetric assessment included mean and maximum (0.03cc) dose, left ventricular volume receiving 5Gy (LV‐V5), and other clinical endpoints. As metrics of plan complexity, total MU and treatment time were evaluated between approaches. Results: Cardiac sparing plans reduced the mean heart dose (mean reduction 0.7 ± 0.6, range 0.1 to 2.5 Gy). Re‐optimized plans reduced left anterior descending artery (LADA) mean and LADA0.03cc (0.0–63.9% and 0.0 to 17.3 Gy, respectively). LV0.03cc was reduced by >1.5 Gy for 10 patients while 6 cases had large reductions (>7%) in LV‐V5. Left atrial mean dose was equivalent/reduced in all sparing plans (mean reduction 0.9 ± 1.2 Gy). The left main coronary artery was better spared in all cases for mean dose and D0.03cc. One patient exhibited >10 Gy reduction in D0.03cc to four substructures. There was no statistical difference in treatment time and MU, or clinical endpoints to the planning target volume, lung, esophagus, or spinal cord after re‐optimization. Four patients benefited from new beam arrangements, leading to further dose reductions. Conclusions: By introducing 0.35T MRIs acquired on an MR‐linac to verify cardiac substructure segmentations for CT‐based treatment planning, an opportunity was presented for more effective sparing with limited increase in plan complexity. Validation in a larger cohort with appropriate margins offers potential to reduce radiation‐related cardiotoxicities. [ABSTRACT FROM AUTHOR]

Purpose: Magnetic resonance‐guided radiation therapy (MRgRT) has shown great promise for localization and real‐time tumor monitoring. However, to date, quantitative imaging has been limited for low field MRgRT. This work benchmarks quantitative T1, R2*, and Proton Density (PD)mapping in a phantom on a 0.35 T MR‐linac and implements a novel acquisition method, STrategically Acquired Gradient Echo (STAGE). To further validate STAGE in a clinical setting, a pilot study was undertaken in a cohort of brain tumor patients to elucidate opportunities for longitudinal functional imaging with an MR‐linac in the brain. Methods: STAGE (two triple‐echo gradient echo (GRE) acquisitions) was optimized for a 0.35T low‐field MR‐linac. Simulations were performed to choose two flip angles to optimize signal‐to‐noise ratio (SNR) and T1‐mapping precision. Tradeoffs between SNR, scan time, and spatial resolution for whole‐brain coverage were evaluated in healthy volunteers. Data were inputted into a STAGE processing pipeline to yield four qualitative images (T1‐weighted, enhanced T1‐weighted, proton‐density (PD) weighted, and simulated FLuid‐Attenuated Inversion Recovery (sFLAIR)), and three quantitative datasets (T1, PD, and R2*). A benchmarking ISMRM/NIST phantom consisting of vials with variable NiCl2 and MnCl2 concentrations was scanned using variable flip angles (VFA) (2–60 degrees) and inversion recovery (IR) methods at 0.35 T. STAGE and VFA T1 values of vials were compared to IR T1 values. As measures of agreement with reference values and repeatability, relative error (RE) and coefficient of variability (CV) were calculated, respectively, for quantitative MR values within the phantom vials (spheres). To demonstrate feasibility, longitudinal STAGE data (pretreatment, weekly, and ~ 2 months post‐treatment) were acquired in an IRB‐approved pilot study of brain tumor cases via the generation of temporal and differential quantitative MRI maps. Results: In the phantom, RE of measured VFA T1 and STAGE relative to IR reference values were 7.0 ± 2.5% and 9.5 ± 2.2% respectively. RE for the PD vials was 8.1 ± 6.8% and CV for phantom R2* measurements was 10.1 ± 9.9%. Simulations and volunteer experiments yielded final STAGE parameters of FA = 50°/10°, 1 × 1 × 3 mm3 resolution, TR = 40 ms, TE = 5/20/34 ms in 10 min (64 slices). In the pilot study of brain tumor patients, differential maps for R2* and T1 maps were sensitive to local tumor changes and appeared similar to 3 T follow‐up MRI datasets. Conclusion: Quantitative T1, R2*, and PD mapping are promising at 0.35 T agreeing well with reference data. STAGE phantom data offer quantitative representations comparable to traditional methods in a fraction of the acquisition time. Initial feasibility of implementing STAGE at 0.35 T in a patient brain tumor cohort suggests that detectable changes can be observed over time. With confirmation in a larger cohort, results may be implemented to identify areas of recurrence and facilitate adaptive radiation therapy. [ABSTRACT FROM AUTHOR]

Purpose: Radiation dose to cardiac substructures is related to radiation‐induced heart disease. However, substructures are not considered in radiation therapy planning (RTP) due to poor visualization on CT. Therefore, we developed a novel deep learning (DL) pipeline leveraging MRI's soft tissue contrast coupled with CT for state‐of‐the‐art cardiac substructure segmentation requiring a single, non‐contrast CT input. Materials/methods: Thirty‐two left‐sided whole‐breast cancer patients underwent cardiac T2 MRI and CT‐simulation. A rigid cardiac‐confined MR/CT registration enabled ground truth delineations of 12 substructures (chambers, great vessels (GVs), coronary arteries (CAs), etc.). Paired MRI/CT data (25 patients) were placed into separate image channels to train a three‐dimensional (3D) neural network using the entire 3D image. Deep supervision and a Dice‐weighted multi‐class loss function were applied. Results were assessed pre/post augmentation and post‐processing (3D conditional random field (CRF)). Results for 11 test CTs (seven unique patients) were compared to ground truth and a multi‐atlas method (MA) via Dice similarity coefficient (DSC), mean distance to agreement (MDA), and Wilcoxon signed‐ranks tests. Three physicians evaluated clinical acceptance via consensus scoring (5‐point scale). Results: The model stabilized in ~19 h (200 epochs, training error <0.001). Augmentation and CRF increased DSC 5.0 ± 7.9% and 1.2 ± 2.5%, across substructures, respectively. DL provided accurate segmentations for chambers (DSC = 0.88 ± 0.03), GVs (DSC = 0.85 ± 0.03), and pulmonary veins (DSC = 0.77 ± 0.04). Combined DSC for CAs was 0.50 ± 0.14. MDA across substructures was <2.0 mm (GV MDA = 1.24 ± 0.31 mm). No substructures had statistical volume differences (P > 0.05) to ground truth. In four cases, DL yielded left main CA contours, whereas MA segmentation failed, and provided improved consensus scores in 44/60 comparisons to MA. DL provided clinically acceptable segmentations for all graded patients for 3/4 chambers. DL contour generation took ~14 s per patient. Conclusions: These promising results suggest DL poses major efficiency and accuracy gains for cardiac substructure segmentation offering high potential for rapid implementation into RTP for improved cardiac sparing. [ABSTRACT FROM AUTHOR]

Model‐based iterative reconstruction (MBIR) reduces CT imaging dose while maintaining image quality. However, MBIR reduces noise while preserving edges which may impact intensity‐based tasks such as auto‐segmentation. This work evaluates the sensitivity of an auto‐contouring prostate atlas across multiple MBIR reconstruction protocols and benchmarks the results against filtered back projection (FBP). Images were created from raw projection data for 11 prostate cancer cases using FBP and nine different MBIR reconstructions (3 protocols/3 noise reduction levels) yielding 10 reconstructions/patient. Five bony structures, bladder, rectum, prostate, and seminal vesicles (SVs) were segmented using an auto‐segmentation pipeline that renders 3D binary masks for analysis. Performance was evaluated for volume percent difference (VPD) and Dice similarity coefficient (DSC), using FBP as the gold standard. Nonparametric Friedman tests plus post hoc all pairwise comparisons were employed to test for significant differences (P < 0.05) for soft tissue organs and protocol/level combinations. A physician performed qualitative grading of 396 MBIR contours across the prostate, bladder, SVs, and rectum in comparison to FBP using a six‐point scale. MBIR contours agreed with FBP for bony anatomy (DSC ≥ 0.98), bladder (DSC ≥ 0.94, VPD < 8.5%), and prostate (DSC = 0.94 ± 0.03, VPD = 4.50 ± 4.77% (range: 0.07–26.39%). Increased variability was observed for rectum (VPD = 7.50 ± 7.56% and DSC = 0.90 ± 0.08) and SVs (VPD and DSC of 8.23 ± 9.86% range (0.00–35.80%) and 0.87 ± 0.11, respectively). Over the all protocol/level comparisons, a significant difference was observed for the prostate VPD between BSPL1 and BSTL2 (adjusted P‐value = 0.039). Nevertheless, 300 of 396 (75.8%) of the four soft tissue structures using MBIR were graded as equivalent or better than FBP, suggesting that MBIR offered potential improvements in auto‐segmentation performance when compared to FBP. Future work may involve tuning organ‐specific MBIR parameters to further improve auto‐segmentation performance. Running title: Impact of CT Reconstruction Algorithm on Auto‐segmentation Performance. [ABSTRACT FROM AUTHOR]

Purpose: MR‐guided radiation therapy (RT) offers unparalleled soft tissue contrast for localization and target tracking. However, MRI distortions may be detrimental to high precision RT. This work characterizes the gradient nonlinearity (GNL) and total distortions over the first year of clinical operation of a 0.35T MR‐linac. Methods: For GNL characterization, an in‐house large field of view (FOV) phantom (60 × 42.5 × 55 cm3, >6000 spherical landmarks) was configured and scanned at four timepoints with forward/reverse read polarities (Gradient Echo sequence, FA/TR/TE = 28°/30 ms/6 ms). GNL was measured in Anterior‐Posterior (AP), Left‐Right (LR), and Superior‐Inferior (SI) frequency‐encoding directions based on deviation of the auto‐segmented landmark centroids between rigidly registered MR and CT images and assessed based on radial distance from magnet isocenter. Total distortion was assessed using a 30 × 30 cm2 grid phantom oriented along the cardinal axes over >1 year of operation. Results: The scanner's spatial integrity within the first ~10 months was stable (maximum total distortion variation = 10/6/8%, maximum distortion = 1.41/0.99/1.56 mm in Axial/Coronal/Sagittal planes, respectively). GNL distortions measured during this time period <10 cm from isocenter were (−0.74, 0.45), (−0.67, 0.53), and (−0.86, 0.70) mm in AP/LR/SI directions. In the 10‐20 cm range, <1.5% of the distortions exceeded 2 mm in the AP and LR axes while <4% of the distortions exceeded 2 mm for SI. After major repairs and magnet re‐shim, detectable changes were observed in total and GNL distortions (20% reduction in AP and 36% increase in SI direction in the 20–25 cm range). Across all timepoints and axes, 38–53% of landmarks in the 20–25 cm range were displaced by >1 mm. Conclusions: GNL distortions were negligible within a 10 cm radius from isocenter. However, in the periphery, non‐negligible distortions of up to ~7 mm were observed, which may necessitate GNL corrections for MR‐IGRT for treatment sites distant from magnet isocenter. [ABSTRACT FROM AUTHOR]

Purpose: With the move towards magnetic resonance imaging (MRI) as a primary treatment planning modality option for men with prostate cancer, it becomes critical to quantify the potential uncertainties introduced for MR‐only planning. This work characterized geometric and dosimetric intra‐fractional changes between the prostate, seminal vesicles (SVs), and organs at risk (OARs) in response to bladder filling conditions. Materials and methods: T2‐weighted and mDixon sequences (3–4 time points/subject, at 1, 1.5 and 3.0 T with totally 34 evaluable time points) were acquired in nine subjects using a fixed bladder filling protocol (bladder void, 20 oz water consumed pre‐imaging, 10 oz mid‐session). Using mDixon images, Magnetic Resonance for Calculating Attenuation (MR‐CAT) synthetic computed tomography (CT) images were generated by classifying voxels as muscle, adipose, spongy, and compact bone and by assignment of bulk Hounsfield Unit values. Organs including the prostate, SVs, bladder, and rectum were delineated on the T2 images at each time point by one physician. The displacement of the prostate and SVs was assessed based on the shift of the center of mass of the delineated organs from the reference state (fullest bladder). Changes in dose plans at different bladder states were assessed based on volumetric modulated arc radiotherapy (VMAT) plans generated for the reference state. Results: Bladder volume reduction of 70 ± 14% from the final to initial time point (relative to the final volume) was observed in the subject population. In the empty bladder condition, the dose delivered to 95% of the planning target volume (PTV) (D95%) reduced significantly for all cases (11.53 ± 6.00%) likely due to anterior shifts of prostate/SVs relative to full bladder conditions. D15% to the bladder increased consistently in all subjects (42.27 ± 40.52%). Changes in D15% to the rectum were patient‐specific, ranging from −23.93% to 22.28% (−0.76 ± 15.30%). Conclusions: Variations in the bladder and rectal volume can significantly dislocate the prostate and OARs, which can negatively impact the dose delivered to these organs. This warrants proper preparation of patients during treatment and imaging sessions, especially when imaging required longer scan times such as MR protocols. [ABSTRACT FROM AUTHOR]

MR‐only treatment planning and MR‐IGRT leverage MRI's powerful soft tissue contrast for high‐precision radiation therapy. However, anthropomorphic MR‐compatible phantoms are currently limited. This work describes the development and evaluation of a custom‐designed, modular, pelvic end‐to‐end (PETE) MR‐compatible phantom to benchmark MR‐only and MR‐IGRT workflows. For construction considerations, subject data were assessed for phantom/skeletal geometry and internal organ kinematics to simulate average male pelvis anatomy. Various materials for the bone, bladder, and rectum were evaluated for utility within the phantom. Once constructed, PETE underwent CT‐SIM, MR‐Linac, and MR‐SIM imaging to qualitatively assess organ visibility. Scans were acquired with various bladder and rectal volumes to assess component interactions, filling capabilities, and filling reproducibility via volume and centroid differences. PETE simulates average male pelvis anatomy and comprises an acrylic body oval (height/width = 23.0/38.1 cm) and a cast‐mold urethane skeleton, with silicone balloons simulating bladder and rectum, a silicone sponge prostate, and hydrophilic poly(vinyl alcohol) foam to simulate fat/tissue separation between organs. Access ports enable retrofitting the phantom with other inserts including point/film‐based dosimetry options. Acceptable contrast was achievable in CT‐SIM and MR‐Linac images. However, the bladder was challenging to distinguish from background in CT‐SIM. The desired contrast for T1‐weighted and T2‐weighted MR‐SIM (dark and bright bladders, respectively) was achieved. Rectum and bone exhibited no MR signal. Inputted volumes differed by <5 and <10 mL from delineated rectum (CT‐SIM) and bladder (MR‐SIM) volumes. Increasing bladder and rectal volumes induced organ displacements and shape variations. Reproduced volumes differed by <4.5 mL, with centroid displacements <1.4 mm. A point dose measurement with an MR‐compatible ion chamber in an MR‐Linac was within 1.5% of expected. A novel, modular phantom was developed with suitable materials and properties that accurately and reproducibly simulate status changes with multiple dosimetry options. Future work includes integrating more realistic organ models to further expand phantom options. [ABSTRACT FROM AUTHOR]