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This work aimed to quantify any principal magnetic field (B 0 ) inhomogeneity and changes in MR image geometric distortion with continuous linac gantry rotation on an Elekta Unity MR-linac. This situation occurs for around a second between treatment beams during current image guided radiotherapy treatment and would occur frequently in foreseeable real-time adaptive radiotherapy treatment. Pixel by pixel maps of B 0 inhomogeneity were obtained via repeated high temporal resolution pulse sequences with the linac gantry static at 36 gantry angles spaced ten degrees apart, and in continuous rotation at both 1 and 2 rpm. Individual B 0 maps were subtracted from average maps across all data and the residual peak to peak inhomogeneity was calculated for each. The bulk geometric shift and change in physical extent of a 10 cm diameter spherical flood phantom during continuous linac gantry rotation at 1 and 2 rpm was compared to the static gantry case for two pulse sequences: the real-time clinical monitoring bFFE sequence and a non-clinical EPI sequence, chosen for its susceptibility to geometric distortion. The peak to peak inhomogeneity in the deviation-from-average ppm maps, plotted against gantry angle with the gantry in continuous rotation at 1 and 2 rpm were negligibly different from equivalent data obtained with the gantry static. The real-time clinical monitoring pulse sequence was shown to give negligible geometric distortion during continuous gantry motion, whilst a non-clinical EPI sequence showed bulk shifts of the order of one pixel and gantry angle dependent changes in extent, demonstrating the sensitivity of the chosen method. MR imaging on the Elekta Unity MR-Linac with the gantry in continuous motion is negligibly different from the static gantry case with current clinical pulse sequences. Real-time tracking and treatment plan adaptation using MR images obtained with the linac gantry in motion is possible.

Online adaptive radiotherapy using the 1.5 Tesla MR-linac is feasible for SBRT (5 × 7 Gy) of pelvic lymph node oligometastases. The workflow allows full online planning based on daily anatomy. Session duration is less than 60 min. Quality assurance tests, including independent 3D dose calculations and film measurements were passed., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Magnetic Resonance linear accelerator (MR-linac) systems represent a new type of technology that allows for online MR-guidance for high precision radiotherapy (RT). Currently, the first MR-linac installations are being introduced clinically. Since the imaging performance of these integrated MR-linac systems is critical for their application, a thorough commissioning of the MRI performance is essential. However, guidelines on the commissioning of MR-guided RT systems are not yet defined and data on the performance of MR-linacs are not yet available., Materials & Methods: Here we describe a comprehensive commissioning protocol, which contains standard MRI performance measurements as well as dedicated hybrid tests that specifically assess the interactions between the Linac and the MRI system. The commissioning results of four MR-linac systems are presented in a multi-center study., Results: Although the four systems showed similar performance in all the standard MRI performance tests, some differences were observed relating to the hybrid character of the systems. Field homogeneity measurements identified differences in the gantry shim configuration, which was later confirmed by the vendor., Conclusion: Our results highlight the importance of dedicated hybrid commissioning tests and the ability to compare the machines between institutes at this very early stage of clinical introduction. Until formal guidelines and tolerances are defined the tests described in this study may be used as a practical guideline. Moreover, the multi-center results provide initial bench mark data for future MR-linac installations., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Stereotactic body radiation therapy (SBRT) has shown great promise in increasing local control rates for renal-cell carcinoma (RCC). Characterized by steep dose gradients and high fraction doses, these hypo-fractionated treatments are, however, prone to dosimetric errors as a result of variations in intra-fraction respiratory-induced motion, such as drifts and amplitude alterations. This may lead to significant variations in the deposited dose. This study aims to develop a method for calculating the accumulated dose for MRI-guided SBRT of RCC in the presence of intra-fraction respiratory variations and determine the effect of such variations on the deposited dose. For this, RCC SBRT treatments were simulated while the underlying anatomy was moving, based on motion information from three motion models with increasing complexity: (1) STATIC, in which static anatomy was assumed, (2) AVG-RESP, in which 4D-MRI phase-volumes were time-weighted, and (3) PCA, a method that generates 3D volumes with sufficient spatio-temporal resolution to capture respiration and intra-fraction variations. Five RCC patients and two volunteers were included and treatments delivery was simulated, using motion derived from subject-specific MR imaging. Motion was most accurately estimated using the PCA method with root-mean-squared errors of 2.7, 2.4, 1.0 mm for STATIC, AVG-RESP and PCA, respectively. The heterogeneous patient group demonstrated relatively large dosimetric differences between the STATIC and AVG-RESP, and the PCA reconstructed dose maps, with hotspots up to [Formula: see text] of the D99 and an underdosed GTV in three out of the five patients. This shows the potential importance of including intra-fraction motion variations in dose calculations.

In radiotherapy, abdominal and thoracic sites are candidates for performing motion tracking. With real-time control it is possible to adjust the multileaf collimator (MLC) position to the target position. However, positions are not perfectly matched and position errors arise from system delays and complicated response of the electromechanic MLC system. Although, it is possible to compensate parts of these errors by using predictors, residual errors remain and need to be compensated to retain target coverage. This work presents a method to statistically describe tracking errors and to automatically derive a patient-specific, per-segment margin to compensate the arising underdosage on-line, i.e. during plan delivery. The statistics of the geometric error between intended and actual machine position are derived using kernel density estimators. Subsequently a margin is calculated on-line according to a selected coverage parameter, which determines the amount of accepted underdosage. The margin is then applied onto the actual segment to accommodate the positioning errors in the enlarged segment. The proof-of-concept was tested in an on-line tracking experiment and showed the ability to recover underdosages for two test cases, increasing [Formula: see text] in the underdosed area about [Formula: see text] and [Formula: see text], respectively. The used dose model was able to predict the loss of dose due to tracking errors and could be used to infer the necessary margins. The implementation had a running time of 23 ms which is compatible with real-time requirements of MLC tracking systems. The auto-adaptivity to machine and patient characteristics makes the technique a generic yet intuitive candidate to avoid underdosages due to MLC tracking errors.

Image processing such as deformable image registration finds its way into radiotherapy as a means to track non-rigid anatomy. With the advent of magnetic resonance imaging (MRI) guided radiotherapy, intrafraction anatomy snapshots become technically feasible. MRI provides the needed tissue signal for high-fidelity image registration. However, acquisitions, especially in 3D, take a considerable amount of time. Pushing towards real-time adaptive radiotherapy, MRI needs to be accelerated without degrading the quality of information. In this paper, we investigate the impact of image resolution on the quality of motion estimations. Potentially, spatially undersampled images yield comparable motion estimations. At the same time, their acquisition times would reduce greatly due to the sparser sampling. In order to substantiate this hypothesis, exemplary 4D datasets of the abdomen were downsampled gradually. Subsequently, spatiotemporal deformations are extracted consistently using the same motion estimation for each downsampled dataset. Errors between the original and the respectively downsampled version of the dataset are then evaluated. Compared to ground-truth, results show high similarity of deformations estimated from downsampled image data. Using a dataset with (2.5 mm)3 voxel size, deformation fields could be recovered well up to a downsampling factor of 2, i.e. (5 mm)3. In a therapy guidance scenario MRI, imaging speed could accordingly increase approximately fourfold, with acceptable loss of estimated motion quality.

Hepatitis C virus (HCV) genotypes were tested by the INNO-LIPA technique and the virus load determined by means of quantitative polymerase chain reaction (PCR) calibrated with standards using sera from 123 HCV patients. Of these 39 were on renal hemolysis treatment, 19 suffered from hemophilia, 13 were i.v. drug users and the remaining 52 had none of these risk factors (chronic hepatitis group). The most prevalent subtype in Austria was 1b, followed by 3a and 1a. However, genotype 1b infections were found relatively less often in hemophiliac patients and drug addicts than in the other two groups. This indicates that hemophiliacs probably had been infected by an antihemophilic plasma stemming from South American or Asian donors. The highest amounts of virus were found in patients infected with genotype 3a. Determination of the patient's virus load and of the infecting subtype may be helpful in planning interferon alpha therapy.