Quality requirements for MRI simulation in cranial stereotactic radiotherapy: a guideline from the German Taskforce "Imaging in Stereotactic Radiotherapy"

Accurate Magnetic Resonance Imaging (MRI) simulation is fundamental for high-precision stereotactic radiosurgery and fractionated stereotactic radiotherapy, collectively referred to as stereotactic radiotherapy (SRT), to deliver doses of high biological effectiveness to well-defined cranial targets. Multiple MRI hardware related factors as well as scanner configuration and sequence protocol parameters can affect the imaging accuracy and need to be optimized for the special purpose of radiotherapy treatment planning. MRI simulation for SRT is possible for different organizational environments including patient referral for imaging as well as dedicated MRI simulation in the radiotherapy department but require radiotherapy-optimized MRI protocols and defined quality standards to ensure geometrically accurate images that form an impeccable foundation for treatment planning. For this guideline, an interdisciplinary panel including experts from the working group for radiosurgery and stereotactic radiotherapy of the German Society for Radiation Oncology (DEGRO), the working group for physics and technology in stereotactic radiotherapy of the German Society for Medical Physics (DGMP), the German Society of Neurosurgery (DGNC), the German Society of Neuroradiology (DGNR) and the German Chapter of the International Society for Magnetic Resonance in Medicine (DS-ISMRM) have defined minimum MRI quality requirements as well as advanced MRI simulation options for cranial SRT.

Deep Brain Stimulation Lead Localization Variability Comparing Intraoperative MRI Versus Postoperative Computed Tomography

BACKGROUND AND OBJECTIVES

Commercially available lead localization software for deep brain stimulation (DBS) often relies on postoperative computed tomography (CT) scans to define electrode positions. When cases are performed with intraoperative MRI, another imaging set exists with which to perform these localizations. To compare DBS localization error between postoperative CT scans and intraoperative MRI.

METHODS

A retrospective cohort of patients who underwent MRI-guided placement of DBS electrodes using the ClearPoint platform was identified. Using Brainlab Elements, postoperative CT scans were coregistered to intraoperative magnetic resonance images visualizing the ClearPoint guidance sheaths and ceramic stylets. DBS electrodes were identified in CT scans using Brainlab's lead localization tool. Trajectory and vector errors were quantified between scans for each lead in each patient.

RESULTS

Eighty patients with a total of 157 implanted DBS electrodes were included. We observed mean trajectory and vector errors of 0.78 ± 0.44 mm (range 0.1-2.0 mm) and 1.57 ± 0.79 mm (range 0.2-4.2 mm), respectively, between postoperative CT and intraoperative MRI. There were 7 patients with CT scans collected at multiple time points. Trajectory error increased by 0.15 ± 0.42 mm ( P = .31), and vector error increased by 0.22 ± 0.53 mm ( P = .13) in the later scans. Across all scans, there was no significant association between trajectory ( P = .053) or vector ( P = .98) error and the date of CT acquisition. DBS electrodes targeting the subthalamic nucleus had significantly greater trajectory errors ( P = .02) than those targeting the globus pallidus pars internus nucleus.

CONCLUSION

Commercially available software produced largely concordant lead localizations when comparing intraoperative MRIs with postoperative CT scans, with trajectory errors on average <1 mm. CT scans tend to be more comparable with intraoperative MRI in the immediate postoperative period, with increased time intervals associated with a greater magnitude of error between modalities.

Geometric distortions in clinical MRI sequences for radiotherapy: insights gained from a multicenter investigation

BACKGROUND

As magnetic resonance imaging (MRI) becomes increasingly integrated into radiotherapy (RT) for enhanced treatment planning and adaptation, the inherent geometric distortion in acquired MR images pose a potential challenge to treatment accuracy. This study aimed to evaluate the geometric distortion levels in the clinical MRI protocols used across Danish RT centers and discuss influence of specific sequence parameters. Based on the variety in geometric performance across centers, we assess if harmonization of MRI sequences is a relevant measure.

MATERIALS AND METHODS

Nine centers participated with 12 MRI scanners and MRI-Linacs (MRL). Using a travelling phantom approach, a reference MRI sequence was used to assess variation in baseline distortion level between scanners. The phantom was also scanned with local clinical MRI sequences for brain, head/neck (H/N), abdomen, and pelvis. The influence of echo time, receiver bandwidth, image weighting, and 2D/3D acquisition was investigated.

RESULTS

We found a large variation in geometric accuracy across 93 clinical sequences examined, exceeding the baseline variation found between MRI scanners (σ = 0.22 mm), except for abdominal sequences where the variation was lower. Brain and abdominal sequences showed lowest distortion levels ([0.22, 2.26] mm), and a large variation in performance was found for H/N and pelvic sequences ([0.19, 4.07] mm). Post hoc analyses revealed that distortion levels decreased with increasing bandwidth and a less clear increase in distortion levels with increasing echo time. 3D MRI sequences had lower distortion levels than 2D (median of 1.10 and 2.10 mm, respectively), and in DWI sequences, the echo-planar imaging read-out resulted in highest distortion levels.

CONCLUSION

There is a large variation in the geometric distortion levels of clinical MRI sequences across Danish RT centers, and between anatomical sites. The large variation observed makes harmonization of MRI sequences across institutions and adoption of practices from well-performing anatomical sites, a relevant measure within RT.

Patient-specific geometrical distortion corrections of MRI images improve dosimetric planning accuracy of vestibular schwannoma treated with gamma knife stereotactic radiosurgery

PURPOSE

To investigate the impact of MRI patient-specific geometrical distortion (PSD) on the quality of Gamma Knife stereotactic radiosurgery (GK-SRS) plans of the vestibular schwannoma (VS) tumors.

METHODS AND MATERIALS

Three open access datasets including the MPI-Leipzig Mind-Brain-Body (318 patients), the slow event-related fMRI designs dataset (62 patients), and the VS dataset (242 patients) were used. We used first two datasets to train a 3D convolution network to predict the distortion map of third dataset that were then used to calculate and correct the PSD. GK-SRS plans of VS dataset were used to evaluate dose distribution of PSD-corrected MRI images. GK-SRS prescription dose of VS cases was 12 Gy. Geometric and dosimetric discrepancies were assessed between the dose distributions and contours before and after the PSD corrections. Geometry indices were center of the contours, Dice coefficient (DC), Hausdorff distance (HD), and dosimetric indices wereD μ ${D_\mu }$ ,D m a x ${D_{max}}$ ,D m i n ${D_{min}}$ , andD 95 % ${D_{95{\mathrm{\% }}}}$ doses, target coverage (TC), Paddick's conformity index (PCI), Paddick's gradient index (GI), and homogeneity index (HI).

RESULTS

Geometric distortions of about 1.2 mm were observed at the air-tissue interfaces at the air canal and nasal cavity borders. Average center of the targets was significantly distorted along the frequency encoding direction after the PSD-correction. Average DC and HD metrics were 0.90 and 2.13 mm. AverageD μ ${D_\mu }$ ,D 95 % , ${D_{95{\mathrm{\% ,}}}}$ andD m i n ${D_{min}}$ in Gy significantly increased after PSD correction from 16.85 to 17.25, 12.30 to 12.77, and from 8.98 to 9.92.D m a x ${D_{max}}$ did not significantly change after the correction. Average TC and PCI significantly increased from 0.97 to 0.98, and 0.94 to 0.96. Average GI decreased significantly from 2.24 to 2.15 after PSD correction. However, HI did not significantly change after the correction.

CONCLUSION

The proposed method could predict and correct the PSD that indicates the importance of PSD correction before GK-SRS plans of the VS patients.

Comprehensive MR imaging QA of 0.35 T MR-Linac using a multi-purpose large FOV phantom: A single-institution experience

PURPOSE

Magnetic resonance-guided radiotherapy (MRgRT) is desired for the treatment of diseases in the abdominothoracic region, which has a broad imaging area and continuous motion. To ensure accurate treatment delivery, an effective image quality assurance (QA) program, with a phantom that covers the field of view (FOV) similar to a human torso, is required. However, routine image QA for a large FOV is not readily available at many MRgRT centers. In this work, we present the clinical experience of the large FOV MRgRT Insight phantom for periodic daily and monthly comprehensive magnetic resonance imaging (MRI)-QA and its feasibility compared to the existing institutional routine MRI-QA procedures in 0.35 T MRgRT.

METHODS

Three phantoms; ViewRay cylindrical water phantom, Fluke 76-907 uniformity and linearity phantom, and Modus QA large FOV MRgRT Insight phantom, were imaged on the 0.35 T MR-Linac. The measurements were made in MRI mode with the true fast imaging with steady-state free precession (TRUFI) sequence. The ViewRay cylindrical water phantom was imaged in a single-position setup whereas the Fluke phantom and Insight phantom were imaged in three different orientations: axial, sagittal, and coronal. Additionally, the phased array coil QA was performed using the horizontal base plate of the Insight phantom by placing the desired coil around the base section which was compared to an in-house built Polyurethane foam phantom for reference.

RESULT

The Insight phantom captured image artifacts across the entire planar field of view, up to 400 mm, in a single image acquisition, which is beyond the FOV of the conventional phantoms. The geometric distortion test showed a similar distortion of 0.45 ± 0.01  and 0.41 ± 0.01 mm near the isocenter, that is, within 300 mm lengths for Fluke and Insight phantoms, respectively, but showed higher geometric distortion of 0.8 ± 0.4 mm in the peripheral region between 300 and 400 mm of the imaging slice for the Insight phantom. The Insight phantom with multiple image quality features and its accompanying software utilized the modulation transform function (MTF) to evaluate the image spatial resolution. The average MTF values were 0.35 ± 0.01, 0.35 ± 0.01, and 0.34 ± 0.03 for axial, coronal, and sagittal images, respectively. The plane alignment and spatial accuracy of the ViewRay water phantom were measured manually. The phased array coil test for both the Insight phantom and the Polyurethane foam phantoms ensured the proper functionality of each coil element.

CONCLUSION

The multifunctional large FOV Insight phantom helps in tracking MR imaging quality of the system to a larger extent compared to the routine daily and monthly QA phantoms currently used in our institute. Also, the Insight phantom is found to be more feasible for routine QA with easy setup.

Usability of magnetic resonance images acquired at a novel low-field 0.55 T scanner for brain radiotherapy treatment planning

Background and Purpose

Low-field magnetic resonance imaging (MRI) may offer specific advantages over high-field MRI, e.g. lower susceptibility-dependent distortions and simpler installation. The study aim was to evaluate if a novel 0.55 T MRI scanner provides sufficient image accuracy and quality for radiotherapy (RT) treatment planning.

Material and methods

The geometric accuracy of images acquired at a low-field MRI scanner was evaluated in phantom measurements regarding gradient non-linearity-related distortions. Patient-induced B0-susceptibility changes were investigated via B0-field-mapping in ten volunteers. Patients were positioned in RT-setup using a 3D-printed insert for the head/neck-coil that was tested for sufficient signal-to-noise-ratio (SNR). The suitability of the MRI-system for detection of metastases was evaluated in eleven patients. In comparison to diagnostic images, acquired at ≥1.5 T, three physicians evaluated the detectability of metastases by counting them in low- and high-field-images, respectively.

Results

The phantom measurements showed a high imaging fidelity after 3D-distortion-correction with (1.2 ± 0.9) mm geometric distortion in 10 cm radius from isocentre. At the edges remaining distortions were greater than at 1.5 T. The mean susceptibility-induced distortions in the head were (0.05 ± 0.05) mm and maximum 0.69 mm. SNR analysis showed that optimised positioning of RT-patients without signal loss in the head/neck-coil was possible with the RT-insert. No significant differences (p = 0.48) in detectability of metastases were found.

Conclusion

The 0.55 T MRI system provided sufficiently geometrically accurate and high-resolution images that can be used for RT-planning for brain metastases. Hence, modern low-field MRI may contribute to simply access MRI for RT-planning after further investigations.

MRI Distortion Correction and Robot-to-MRI Scanner Registration for an MRI-Guided Robotic System

Magnetic resonance imaging (MRI) guided robotic procedures require safe robotic instrument navigation and precise target localization. This depends on reliable tracking of the instrument from MR images, which requires accurate registration of the robot to the scanner. A novel differential image based robot-to-MRI scanner registration approach is proposed that utilizes a set of active fiducial coils, where background subtraction method is employed for coil detection. In order to use the presented preoperative registration approach jointly with the real-time high speed MRI image acquisition and reconstruction methods in real-time interventional procedures, the effects of the geometric MRI distortion in robot to scanner registration is analyzed using a custom distortion mapping algorithm. The proposed approach is validated by a set of target coils placed within the workspace, employing multi-planar capabilities of the scanner. Registration and validation errors are respectively 2.05 mm and 2.63 mm after the distortion correction showing an improvement of respectively 1.08 mm and 0.14 mm compared to the results without distortion correction.

Development of a vendor neutral MRI distortion quality assurance workflow

With the utilization of magnetic resonance (MR) imaging in radiotherapy increasing, routine quality assurance (QA) of these systems is necessary. The assessment of geometric distortion in images used for radiotherapy treatment planning needs to be quantified and monitored over time. This work presents an adaptable methodology for performing routine QA for systematic MRI geometric distortion. A software tool and compatible protocol (designed to work with any CT and MR compatible phantom on any scanner) were developed to quantify geometric distortion via deformable image registration. The MR image is deformed to the CT, generating a deformation field, which is sampled, quantifying geometric distortion as a function of distance from scanner isocenter. Configurability of the QA tool was tested, and results compared to those provided from commercial solutions. Registration accuracy was investigated by repeating the deformable registration step on the initial deformed MR image to define regions with residual distortions. The geometric distortion of four clinical systems was quantified using the customisable QA method presented. Maximum measured distortions varied from 2.2 to 19.4 mm (image parameter and sampling volume dependent). The workflow was successfully customized for different phantom configurations and volunteer imaging studies. Comparison to a vendor supplied solution showed good agreement in regions where the two procedures were sampling the same imaging volume. On a large field of view phantom across various scanners, the QA tool accurately quantified geometric distortions within 17–22 cm from scanner isocenter. Beyond these regions, the geometric integrity of images in clinical applications should be considered with a higher degree of uncertainty due to increased gradient nonlinearity and B₀ inhomogeneity. This tool has been successfully integrated into routine QA of the MRI scanner utilized for radiotherapy within our department. It enables any low susceptibility MR‐CT compatible phantom to quantify the geometric distortion on any MRI scanner with a configurable, user friendly interface for ease of use and consistency in data collection and analysis.

Prostate MRI in Stereotactic Body Radiation Treatment Planning and Delivery for Localized Prostate Cancer

Prostate MRI is increasingly being used to make diagnoses and guide management for patients receiving definitive radiation treatment for prostate cancer. Radiologists should be familiar with the potential uses of prostate MRI in radiation therapy planning and delivery. Radiation therapy is an established option for the definitive treatment of localized prostate cancer. Stereotactic body radiation therapy (SBRT) is an external-beam radiation therapy method used to deliver a high dose of radiation to an extracranial target in the body, often in five or fewer fractions. SBRT is increasingly being used for prostate cancer treatment and has been recognized by the National Comprehensive Cancer Network as an acceptable definitive treatment regimen for low-, intermediate-, and high-risk prostate cancer. MRI is commonly used to aid in prostate radiation therapy. The authors review the uses of prostate MRI in SBRT treatment planning and delivery. Specific topics discussed include the use of prostate MRI for identification of and dose reduction to the membranous and prostatic urethra, which can decrease the risk of acute and late toxicities. MRI is also useful for identification and appropriate dose coverage of the prostate apex and areas of extraprostatic extension or seminal vesicle invasion. In prospective studies, prostate MRI is being validated for identification of and dose intensification to dominant intraprostatic lesions, which potentially can improve oncologic outcomes. It also can be used to evaluate the placement of fiducial markers and hydrogel spacers for radiation therapy planning and delivery. ^©RSNA, 2022.

Increased brain volumetric measurement precision from multi-site 3D T1-weighted 3 T magnetic resonance imaging by correcting geometric distortions

PURPOSE

Magnetic resonance imaging (MRI) scanner-specific geometric distortions may contribute to scanner induced variability and decrease volumetric measurement precision for multi-site studies. The purpose of this study was to determine whether geometric distortion correction increases the precision of brain volumetric measurements in a multi-site multi-scanner study.

METHODS

Geometric distortion variation was quantified over a one-year period at 10 sites using the distortion fields estimated from monthly 3D T1-weighted MRI geometrical phantom scans. The variability of volume and distance measurements were quantified using synthetic volumes and a standard quantitative MRI (qMRI) phantom. The effects of geometric distortion corrections on MRI derived volumetric measurements of the human brain were assessed in two subjects scanned on each of the 10 MRI scanners and in 150 subjects with cerebrovascaular disease (CVD) acquired across imaging sites.

RESULTS

Geometric distortions were found to vary substantially between different MRI scanners but were relatively stable on each scanner over a one-year interval. Geometric distortions varied spatially, increasing in severity with distance from the magnet isocenter. In measurements made with the qMRI phantom, the geometric distortion correction decreased the standard deviation of volumetric assessments by 35% and distance measurements by 42%. The average coefficient of variance decreased by 16% in gray matter and white matter volume estimates in the two subjects scanned on the 10 MRI scanners.

CONCLUSION

Geometric distortion correction using an up-to-date correction field is recommended to increase precision in volumetric measurements made from MRI images.

Characterizing geometric distortions of 3D sequences in clinical head MRI

Objective

Phantoms are often used to estimate the geometric accuracy in magnetic resonance imaging (MRI). However, the distortions may differ between anatomical and phantom images. This study aimed to investigate the applicability of a phantom-based and a test-subject-based method in evaluating geometric distortion present in clinical head-imaging sequences.

Materials and methods

We imaged a 3D-printed phantom and test subjects with two MRI scanners using two clinical head-imaging 3D sequences with varying patient-table positions and receiver bandwidths. The geometric distortions were evaluated through nonrigid registrations: the displaced acquisitions were compared against the ideal isocenter positioning, and the varied bandwidth volumes against the volume with the highest bandwidth. The phantom acquisitions were also registered to a computed tomography scan.

Results

Geometric distortion magnitudes increased with larger table displacements and were in good agreement between the phantom and test-subject acquisitions. The effect of increased distortions with decreasing receiver bandwidth was more prominent for test-subject acquisitions.

Conclusion

Presented results emphasize the sensitivity of the geometric accuracy to positioning and imaging parameters. Phantom limitations may become an issue with some sequence types, encouraging the use of anatomical images for evaluating the geometric accuracy.

Geometric distortion assessment in 3T MR images used for treatment planning in cranial Stereotactic Radiosurgery and Radiotherapy

Magnetic Resonance images (MRIs) are employed in brain Stereotactic Radiosurgery and Radiotherapy (SRS/SRT) for target and/or critical organ localization and delineation. However, MRIs are inherently distorted, which also impacts the accuracy of the Magnetic Resonance Imaging/Computed Tomography (MRI/CT) co-registration process. In this phantom-based study, geometric distortion is assessed in 3T T2-weighted images (T2WIs), while the efficacy of an MRI distortion correction technique is also evaluated. A homogeneous polymer gel-filled phantom was CT-imaged before being irradiated with 26 4-mm Gamma Knife shots at predefined locations (reference control points). The irradiated phantom was MRI-scanned at 3T, implementing a T2-weighted protocol suitable for SRS/SRT treatment planning. The centers of mass of all shots were identified in the 3D image space by implementing an iterative localization algorithm and served as the evaluated control points for MRI distortion detection. MRIs and CT images were spatially co-registered using a mutual information algorithm. The inverse transformation matrix was applied to the reference control points and compared with the corresponding MRI-identified ones to evaluate the overall spatial accuracy of the MRI/CT dataset. The mean image distortion correction technique was implemented, and resulting MRI-corrected control points were compared against the corresponding reference ones. For the scanning parameters used, increased MRI distortion (>1mm) was detected at areas distant from the MRI isocenter (>5cm), while median radial distortion was 0.76mm. Detected offsets were slightly higher for the MRI/CT dataset (0.92mm median distortion). The mean image distortion correction improves geometric accuracy, but residual distortion cannot be considered negligible (0.51mm median distortion). For all three datasets studied, a statistically significant positive correlation between detected spatial offsets and their distance from the MRI isocenter was revealed. This work contributes towards the wider adoption of 3T imaging in SRS/SRT treatment planning. The presented methodology can be employed in commissioning and quality assurance programmes of corresponding treatment workflows.

Target localization accuracy in frame‐based stereotactic radiosurgery: Comparison between MR‐only and MR/CT co‐registration approaches

Purpose

In frame‐based Gamma Knife (GK) stereotactic radiosurgery two treatment planning workflows are commonly employed; one based solely on magnetic resonance (MR) images and the other based on magnetic resonance/computed tomography (MR/CT) co‐registered images. In both workflows, target localization accuracy (TLA) can be deteriorated due to MR‐related geometric distortions and/or MR/CT co‐registration uncertainties. In this study, the overall TLA following both clinical workflows is evaluated for cases of multiple brain metastases.

Methods

A polymer gel‐filled head phantom, having the Leksell stereotactic headframe attached, was CT‐imaged and irradiated by a GK Perfexion unit. A total of 26 4‐mm shots were delivered at 26 locations directly defined in the Leksell stereotactic space (LSS), inducing adequate contrast in corresponding T2‐weighted (T2w) MR images. Prescribed shot coordinates served as reference locations. An additional MR scan was acquired to implement the “mean image” distortion correction technique. The TLA for each workflow was assessed by comparing the radiation‐induced target locations, identified in MR images, with corresponding reference locations. Using T1w MR and CT images of 15 patients (totaling 81 lesions), TLA in clinical cases was similarly assessed, considering MR‐corrected data as reference. For the MR/CT workflow, both global and region of interest (ROI)‐based MR/CT registration approaches were studied.

Results

In phantom measurements, the MR‐corrected workflow demonstrated unsurpassed TLA (median offset of 0.2 mm) which deteriorated for MR‐only and MR/CT workflows (median offsets of 0.8 and 0.6 mm, respectively). In real‐patient cases, the MR‐only workflow resulted in offsets that exhibit a significant positive correlation with the distance from the MR isocenter, reaching 1.1 mm (median 0.6 mm). Comparable results were obtained for the MR/CT‐global workflow, although a maximum offset of 1.4 mm was detected. TLA was improved with the MR/CT‐ROI workflow resulting in median/maximum offsets of 0.4 mm/1.1 mm.

Conclusions

Subpixel TLA is achievable in all workflows. For the MR/CT workflow, a ROI‐based MR/CT co‐registration approach could considerably increase TLA and should be preferred instead of a global registration.

Phantom assessment of three-dimensional geometric distortion of a dedicated wide-bore MR-simulator for radiotherapy

This study evaluated the machine-dependent three-dimensional geometric distortion images acquired from a 1.5T 700mm-wide bore MR-simulator based on a large geometric accuracy phantom. With the consideration of radiation therapy (RT) application requirements, every sequence was examined in various combinations of acquisition-orientations and receiver-bandwidths with console-integrated distortion correction enabled. Distortion was repeatedly measured over a six-month period. The distortion measured from the images acquired at the beginning of this period was employed to retrospectively correct the distortion in the subsequent acquisitions. Geometric distortion was analyzed within the largest field-of-view allowed. Six sequences were examined for comprehensive distortion analysis - VIBE, SPACE, TSE, FLASH, BLADE and PETRA. Based on optimal acquisition parameters, their diameter-sphere-volumes (DSVs) of CT-comparable geometric fidelity (where 1mm distortion was allowed) were 333.6mm, 315.1mm, 316.0mm, 318.9mm, 306.2mm and 314.5mm respectively. This was a significant increase from 254.0mm, 245.5mm, 228.9mm, 256.6mm, 230.8mm and 254.2mm DSVs respectively, when images were acquired using un-optimized parameters. The longitudinal stability of geometric distortion and the efficacy of retrospective correction of console-corrected images, based on prior distortion measurements, were inspected using VIBE and SPACE. The retrospectively corrected images achieved over 500mm DSVs with 1mm distortion allowed. The median distortion was below 1mm after retrospective correction, proving that obtaining prior distortion map for subsequent retrospective distortion correction is beneficial. The systematic evaluation of distortion using various combinations of sequence-type, acquisition-orientation and receiver-bandwidth in a six-month time span would be a valuable guideline for optimizing sequence for various RT applications.

Design and construction of a customizable phantom for the characterization of the three-dimensional magnetic resonance imaging geometric distortion

One of the main challenges to using magnetic resonance imaging (MRI) in radiotherapy is the existence of system‐related geometric inaccuracies caused mainly by the inhomogeneity in the main magnetic field and the nonlinearities of the gradient coils.

Several physical phantoms, with fixed configuration, have been developed and commercialized for the assessment of the MRI geometric distortion. In this study, we propose a new design of a customizable phantom that can fit any type of radio frequency (RF) coil. It is composed of 3D printed plastic blocks containing holes that can hold glass tubes which can be filled with any liquid. The blocks can be assembled to construct phantoms with any dimension.

The feasibility of this design has been demonstrated by assembling four phantoms with high robustness allowing the assessment of the geometric distortion for the GE split head coil, the head and neck array coil, the anterior array coil, and the body coil. Phantom reproducibility was evaluated by analyzing the geometric distortion on CT acquisition of five independent assemblages of the phantom.

This solution meets all expectations in terms of having a robust, lightweight, modular, and practical tool for measuring distortion in three dimensions. Mean error in the position of the tubes was less than 0.2 mm. For the geometric distortion, our results showed that for all typical MRI sequences used for radiotherapy, the mean geometric distortion was less than 1 mm and less than 2.5 mm over radial distances of 150 mm and 250 mm, respectively.

These tools will be part of a quality assurance program aimed at monitoring the image quality of MRI scanners used to guide radiation therapy.

Task group 284 report: magnetic resonance imaging simulation in radiotherapy: considerations for clinical implementation, optimization, and quality assurance

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.

ReUINet: A fast GNL distortion correction approach on a 1.0 T MRI-Linac scanner

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.

Evaluation of the influence of susceptibility-induced magnetic field distortions on the precision of contouring intracranial organs at risk for stereotactic radiosurgery

•

45 data sets (18 on a 1.5 T MR and 27 on a 3 T MR) were evaluated for susceptibility induced distortions.

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Maximum distortions of up to 1.7 mm were found for organs at risk in standard diagnostic settings.

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Median distortions ranged between 0.1 and 0.2 mm for all organs at risk.

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Active shimming was estimated to reduce distortions by a factor of 2.3 to 2.9.

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A safety margin of 1 mm would have encompassed 99.8% of the distortions.

Background and purpose

Magnetic resonance imaging (MRI) is a crucial factor in optimal treatment planning for stereotactic radiosurgery. To further the awareness of possible errors in MRI, this work aimed to investigate the magnitude of susceptibility induced MRI distortions for intracranial organs at risk (OARs) and test the effectiveness of actively shimming these distortions.

Materials and methods

Distortion maps for 45 exams of 42 patients (18 on a 1.5 T MRI scanner, 27 on a 3 T MRI scanner) were calculated based on a high-bandwidth double-echo gradient echo sequence. The investigated OARs were brainstem, chiasm, eyes, and optic nerves. The influence of active shimming was investigated by comparing unshimmed 1.5 T data with shimmed 3 T data and comparing the results to a model based prediction.

Results

The median distortion for the different OARs was found to be between 0.13 and 0.18 mm for 1.5 T and between 0.11 and 0.13 mm for 3 T. The maximum distortion was found to be between 1.3 and 1.7 mm for 1.5 T and between 1.1 and 1.4 mm for 3 T. The variation of values was much higher for 1.5 T than for 3 T across all investigated OARs. Active shimming was found to reduce distortions by a factor of 2.3 to 2.9 compared to the expected values.

Conclusions

Using a safety margin for OARs of 1 mm would have encompassed 99.8% of the distortions. Since distortions are inversely proportional to the readout bandwidth, they can be further reduced by increasing the bandwidth. Additional error sources like gradient nonlinearities need to be addressed separately.

Evaluation of patient-specific MR distortion correction schemes for improved target localization accuracy in SRS

PURPOSE

This work aims at promoting target localization accuracy in cranial stereotactic radiosurgery (SRS) applications by focusing on the correction of sequence-dependent (also patient induced) magnetic resonance (MR) distortions at the lesion locations. A phantom-based quality assurance (QA) methodology was developed and implemented for the evaluation of three distortion correction techniques. The same approach was also adapted to cranial MR images used for SRS treatment planning purposes in single or multiple brain metastases cases.

METHODS

A three-dimensional (3D)-printed head phantom was filled with a 3D polymer gel dosimeter. Following treatment planning and dose delivery, volumes of radiation-induced polymerization served as hypothetical lesions, offering adequate MR contrast with respect to the surrounding unirradiated areas. T1-weighted (T1w) MR imaging was performed at 1.5 T using the clinical scanning protocol for SRS. Additional images were acquired to implement three distortion correction methods; the field mapping (FM), mean image (MI) and signal integration (SI) techniques. Reference lesion locations were calculated as the averaged centroid positions of each target identified in the forward and reverse read gradient polarity MRI scans. The same techniques and workflows were implemented for the correction of contrast-enhanced T1w MR images of 10 patients with a total of 27 brain metastases.

RESULTS

All methods employed in the phantom study diminished spatial distortion. Median and maximum distortion magnitude decreased from 0.7 mm (2.10 ppm) and 0.8 mm (2.36 ppm), respectively, to <0.2 mm (0.61 ppm) at all target locations, using any of the three techniques. Image quality of the corrected images was acceptable, while contrast-to-noise ratio slightly increased. Results of the patient study were in accordance with the findings of the phantom study. Residual distortion in corrected patient images was found to be <0.3 mm in the vast majority of targets. Overall, the MI approach appears to be the most efficient correction method from the three investigated.

CONCLUSIONS

In cranial SRS applications, patient-specific distortion correction at the target location(s) is feasible and effective, despite the expense of longer imaging time since additional MRI scan(s) need to be performed. A phantom-based QA methodology was developed and presented to reassure efficient implementation of correction techniques for sequence-dependent spatial distortion.

Characterization of hardware-related spatial distortions for IR-PETRA pulse sequence using a brain specific phantom

OBJECTIVE

Inversion recovery-pointwise encoding time reduction with radial acquisition (IR-PETRA) is an effective magnetic resonance (MR) pulse sequence in generating pseudo-CTs. The hardware-related spatial-distortion (HRSD) in MR images potentially deteriorates the accuracy of pseudo-CTs. Thus, we aimed at characterizing HRSD for IR-PETRA.

MATERIALS AND METHODS

gross-HRSD_overall (Euclidean-sum of gross-HRSD_i (i = x, y, z)) for IR-PETRA was assessed using a brain-specific phantom for two MR scanners (1.5 T-Aera and 3.0 T-Prisma). Moreover, hardware imperfections were analyzed by determining gradient-nonlinearity spatial-distortion (GNSD) and B₀-inhomogeneity spatial-distortion (B₀ISD) for magnetization-prepared rapid acquisition gradient-echo (MP-RAGE) which has well-known distortion characteristics.

RESULTS

In 3.0 T, maximum of gross-GNSD_overall (Euclidean-sum of gross-GNSD_i) and gross-B₀ISD for MP-RAGE was 2.77 mm and 0.57 mm, respectively. For this scanner, the mean and maximum of gross-HRSD_overall for IR-PETRA were 0.63 ± 0.38 mm and 1.91 mm, respectively. In 1.5 T, maximum of gross-GNSD_overall and gross-B₀ISD for MP-RAGE was 3.41 mm and 0.78 mm, respectively. The mean and maximum of gross-HRSD_overall for IR-PETRA were 1.02 ± 0.50 mm and 3.12 mm, respectively.

DISCUSSION

The spatial accuracy of MR images, besides being impacted by hardware performance, scanner capabilities, and imaging parameters, is mainly affected by its imaging strategy and data acquisition scheme. In 3.0 T, even without applying vendor correction algorithms, spatial accuracy of IR-PETRA image is sufficient for generating pseudo-CTs. In 1.5 T, distortion-correction is required to provide this accuracy.

Commissioning of a 1.5T Elekta Unity MR-linac: A single institution experience

MR image-guided radiotherapy has the potential to improve patient care, but integration of an MRI scanner with a linear accelerator adds complexity to the commissioning process. This work describes a single institution experience of commissioning an Elekta Unity MR-linac, including mechanical testing, MRI scanner commissioning, and dosimetric validation. Mechanical testing included multileaf collimator (MLC) positional accuracy, measurement of radiation isocenter diameter, and MR-to-MV coincidence. Key MRI tests included magnetic field homogeneity, geometric accuracy, image quality, and the accuracy of navigator-triggered imaging for motion management. Dosimetric validation consisted of comparison between measured and calculated PDDs and profiles, IMRT measurements, and end-to-end testing. Multileaf collimator positional accuracy was within 1.0 mm, the measured radiation isocenter walkout was 0.20 mm, and the coincidence between MR and MV isocenter was 1.06 mm, which is accounted for in the treatment planning system (TPS). For a 350-mm-diameter spherical volume, the peak-to-peak deviation of the magnetic field homogeneity was 4.44 ppm and the geometric distortion was 0.8 mm. All image quality metrics were within ACR recommendations. Navigator-triggered images showed a maximum deviation of 0.42, 0.75, and 3.0 mm in the target centroid location compared to the stationary target for a 20 mm motion at 10, 15, and 20 breaths per minute, respectively. TPS-calculated PDDs and profiles showed excellent agreement with measurement. The gamma passing rate for IMRT plans was 98.4 ± 1.1% (3%/ 2 mm) and end-to-end testing of adapted plans showed agreement within 0.4% between ion-chamber measurement and TPS calculation. All credentialing criteria were satisfied in an independent end-to-end test using an IROC MRgRT phantom.

Magnetic resonance imaging for brain stereotactic radiotherapy : A review of requirements and pitfalls

Due to its superior soft tissue contrast, magnetic resonance imaging (MRI) is essential for many radiotherapy treatment indications. This is especially true for treatment planning in intracranial tumors, where MRI has a long-standing history for target delineation in clinical practice. Despite its routine use, care has to be taken when selecting and acquiring MRI studies for the purpose of radiotherapy treatment planning. Requirements on MRI are particularly demanding for intracranial stereotactic radiotherapy, where accurate imaging has a critical role in treatment success. However, MR images acquired for routine radiological assessment are frequently unsuitable for high-precision stereotactic radiotherapy as the requirements for imaging are significantly different for radiotherapy planning and diagnostic radiology. To assure that optimal imaging is used for treatment planning, the radiation oncologist needs proper knowledge of the most important requirements concerning the use of MRI in brain stereotactic radiotherapy. In the present review, we summarize and discuss the most relevant issues when using MR images for target volume delineation in intracranial stereotactic radiotherapy.

Dosimetric impact of rotational errors on the quality of VMAT-SRS for multiple brain metastases: Comparison between single- and two-isocenter treatment planning techniques

Purpose

In the absence of a 6D couch and/or assuming considerable intrafractional patient motion, rotational errors could affect target coverage and OAR‐sparing especially in multiple metastases VMAT‐SRS cranial cases, which often involve the concurrent irradiation of off‐axis targets. This work aims to study the dosimetric impact of rotational errors in such applications, under a comparative perspective between the single‐ and two‐isocenter treatment techniques.

Methods

Ten patients (36 metastases) were included in this study. Challenging cases were only considered, with several targets lying in close proximity to OARs. Two multiarc VMAT plans per patient were prepared, involving one and two isocenters, serving as the reference plans. Different degrees of angular offsets at various orientations were introduced, simulating rotational errors. Resulting dose distributions were evaluated and compared using commonly employed dose‐volume and plan quality indices.

Results

For single‐isocenter plans and 1^⁰ rotations, plan quality indices, such as coverage, conformity index and D_95%, deteriorated significantly (>5%) for distant targets from the isocenter (at> 4–6 cm). Contrarily, for two‐isocenter plans, target distances to nearest isocenter were always shorter (≤4 cm), and, consequently, 1^⁰ errors were well‐tolerated. In the most extreme case considered (2^⁰ around all axes) conformity index deteriorated by on‐average 7.2%/cm of distance to isocenter, if one isocenter is used, and 2.6%/cm, for plans involving two isocenters. The effect is, however, strongly associated with target volume. Regarding OARs, for single‐isocenter plans, significant increase (up to 63%) in D_max and D_0.02cc values was observed for any angle of rotation. Plans that could be considered clinically unacceptable were obtained even for the smallest angle considered, although rarer for the two‐isocenter planning approach.

Conclusion

Limiting the lesion‐to‐isocenter distance to ≤4 cm by introducing additional isocenter(s) appears to partly mitigate severe target underdosage, especially for smaller target sizes. If OAR‐sparing is also a concern, more stringent rotational error tolerances apply.

Evaluating the accuracy of geometrical distortion correction of magnetic resonance images for use in intracranial brain tumor radiotherapy

Aim

Determine the 1) effectiveness of correction for gradient-non-linearity and susceptibility effects on both QUASAR GRID^3D and CIRS phantoms; and 2) the magnitude and location of regions of residual distortion before and after correction.

Background

Using magnetic resonance imaging (MRI) as a primary dataset for radiotherapy planning requires correction for geometrical distortion and non-uniform intensity.

Materials and Methods

Phantom Study: MRI, computed tomography (CT) and cone beam CT images of QUASAR GRID^3D and CIRS head phantoms were acquired. Patient Study: Ten patients were MRI-scanned for stereotactic radiosurgery treatment. Correction algorithm: Two magnitude and one phase difference image were acquired to create a field map. A MATLAB program was used to calculate geometrical distortion in the frequency encoding direction, and 3D interpolation was applied to resize it to match 3D T1-weighted magnetization-prepared rapid gradient-echo (MPRAGE) images. MPRAGE images were warped according to the interpolated field map in the frequency encoding direction. The corrected and uncorrected MRI images were fused, deformable registered, and a difference distortion map generated.

Results

Maximum deviation improvements: GRID^3D , 0.27 mm y-direction, 0.07 mm z-direction, 0.23 mm x-direction. CIRS, 0.34 mm, 0.1 mm and 0.09 mm at 20-, 40- and 60-mm diameters from the isocenter. Patient data show corrections from 0.2 to 1.2 mm, based on location. The most-distorted areas are around air cavities, e.g. sinuses.

Conclusions

The phantom data show the validity of our fast distortion correction algorithm. Patient-specific data are acquired in <2 min and analyzed and available for planning in less than a minute.

Exploratory study of geometric distortion correction of prostate diffusion-weighted imaging using B0 map acquisition

BACKGROUND

Evaluation of prostate MRI relies on diffusion-weighted imaging (DWI), commonly distorted by susceptibility artifacts, thereby creating a need for approaches to correct such distortion.

PURPOSE

To compare geometric distortion on prostate MRI between standard DWI and a geometric distortion correction method for DWI described as static distortion correction DWI (SDC DWI).

STUDY TYPE

Retrospective case study.

POPULATION

Thirty patients (ages 31-81 years) undergoing prostate MRI.

SEQUENCE

Geometric distortions from echo planar imaging were corrected with the SDC DWI protocol, which first acquires a B₀ -field map to estimate geometric distortions.

ASSESSMENT

Contours of the prostate were placed on axial T₂ -weighted imaging (T₂ WI) as an anatomic standard. Pixel shifts and apparent diffusion coefficient (ADC) values were compared between prostate contours applied to the SDC DWI and standard DWI sequences. Detailed characterization of the impact of SDC DWI was performed in three representative patients.

STATISTICAL TESTS

One-way analysis of variance (ANOVA) test, Spearman correlation test, and Bland-Altman plots were calculated.

RESULTS

There was significantly greater overlap of the SDC DWI prostate region of interest (ROI) with T₂ WI than standard DWI with T₂ WI (10.56 cm² ± 3.14, P < 0.05). R² of ADC values from standard DWI vs. SDC DWI in the 30 patients ranged from 0.02-0.94 (mean 0.60). A patient without susceptibility artifact demonstrated minimal pixel shift ranging from 0.6-1.3 mm and high correlation of ADC values (R² = 0.89) between SDC DWI and standard DWI. A patient with rectal gas showed greater pixel shift (range: -2.5 to -0.5 mm) and less ADC value correlation (R² = 0.69). A patient with a pelvic phlebolith adjacent to the prostate showed an even greater pixel shift (range: 10-16 mm) and decreased ADC correlation (R² = 0.21).

DATA CONCLUSION

SDC DWI appears to correct for susceptibility-related pixel shifts in the prostate compared with standard DWI, which may have value for assessing prostate lesions obscured by geometric warping. Level of Evidence 4 Technical Efficacy Stage 1 J. Magn. Reson. Imaging 2019;50:1614-1619.

Evaluation of the Geometric and Dosimetric Accuracy of Synthetic Computed Tomography Images for Magnetic Resonance Imaging-only Stereotactic Radiosurgery

Introduction

Stereotactic radiosurgery (SRS) plans created using synthetic computed tomography (CT) images derived from magnetic resonance imaging (MRI) data may offer the advantage of inhomogeneity correction by convolution algorithms, as is done for CT-based plans. We sought to determine and validate the clinical significance and accuracy of synthetic CT images for inhomogeneity correction in MRI-only stereotactic radiosurgery plans for treatment of brain tumors.

Methods

In this retrospective study, data from two patients with brain metastases and one with meningioma who underwent imaging with multiple modalities and received frameless SRS treatment were analyzed. The SRS plans were generated using a convolution algorithm to account for brain inhomogeneity using CT and synthetic CT images and compared with the original clinical TMR10 plans created using MRI images.

Results

Synthetic CT-derived SRS plans are comparable with CT-based plans using convolution algorithm, and for some targets, based on location, they provided better coverage and a lower maximum dose.

Conclusions

The results suggest similar dose delivery results for CT and synthetic CT-based treatment plans. Synthetic CT plans offered a noticeable improvement in target dose coverage and a more gradual dose fall-off relative to TMR10 MRI-based plans. The major disadvantage is a slightly increased dose (by 0.37%) to nearby healthy tissue (brainstem) for synthetic CT-based plans relative to those created using clinical MRI images, which may be a problem for patients undergoing high-dose treatment.

Large field of view distortion assessment in a low-field MR-linac

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.

On the total system error of a robotic radiosurgery system: phantom measurements, clinical evaluation and long-term analysis

The total system error (TSE) of a CyberKnife^® system was measured using two phantom-based methods and one patient-based method. The standard radiochromic film (RCF) end-to-end (E2E) test using an anthropomorphic head and neck phantom and isocentric treatment delivery was used with the 6Dskull, Fiducial and Xsight^® spine (XST) tracking methods. More than 200 RCF-based E2E results covering the period from installation in 2006 until 2017 were analyzed with respect to tracking method, system hardware and software versions, secondary collimation system, and years since installation. An independent polymer gel E2E method was also applied, involving a 3D printed head phantom and multiple spherical target volumes widely distributed within the brain. Finally, the TSE was assessed by comparing the delineated target in the planning computed tomography images of a patient treated for a thalamic functional target with the radiation-induced lesion defined on the six-month follow-up magnetic resonance (MR) images. Statistical analysis of the RCF-based TSE results showed mean  ±  standard deviation values of 0.40  ±  0.18 mm, 0.40  ±  0.19 mm, and 0.55  ±  0.20 mm for the 6Dskull, Fiducial, and XST tracking methods, respectively. Polymer gel TSE values smaller than 0.66 mm were found for seven targets distributed within the brain, showing that the targeting accuracy of the system is sustained even for targets situated up to 80 mm away from the center of the skull. An average clinical TSE value of 0.87  ±  0.25 mm was also measured using the FSE T2 and FLAIR post-treatment MR image data. Analysis of the long-term RCF-based E2E tests showed no changes of TSE over time. This study is the first to report long-term (>10 years) analysis of TSE, TSE measurement for targets positioned at large distances from the virtual machine isocenter, or a clinical assessment of TSE for the CyberKnife system. All of these measurements demonstrate TSE consistently  <  1 mm.

Per-organ assessment of subject-induced susceptibility distortion for MR-only male pelvis treatment planning

Background

Patient-specific distortions, particularly near tissue/air interfaces, require assessment for magnetic resonance (MR) only radiation treatment planning (RTP). However, patients are dynamic due to changes in physiological status during imaging sessions. This work investigated changes in subject-induced susceptibility distortions to pelvic organs at different bladder states to support pelvis MR-only RTP.

Methods

Pelvises of 9 healthy male volunteers were imaged at 1.0 Tesla (T), 1.5 T, and 3.0 T. Subject-induced susceptibility distortion field maps were generated using a dual-echo gradient-recalled echo (GRE) sequence with B₀ field maps obtained from the phase difference between the two echoes acquired at several bladder volume states (3–4/subject, 32 overall). T2 turbo spin echo images were also acquired at each bladder state for organ delineation. Magnet central frequency was tracked over time. Distortion map differences and boxplots were computed to characterize changes within the clinical target volume (CTV), bladder, seminal vesicles, and prostate volumes.

Results

The time between the initial and final B0 maps was 42.6 ± 13.9 (range: 13.2–62.1) minutes with minimal change in magnet central frequency (0.02 ± 0.05 mm (range: − 0.06 – 0.12 mm)). Subject-induced susceptibility distortion across all bladder states, field strengths, and subjects was relatively small (1.4–1.9% of all voxels in the prostate and seminal vesicles were distorted > 0.5 mm). In the bladder, no voxels exhibited distortions > 1 mm. An extreme case acquired at 3.0 T with a large volume of rectal air yielded 27.4–34.6% of voxels within the CTVs had susceptibility-induced distortions > 0.5 mm across all time points.

Conclusions

Our work suggests that subject-induced susceptibility distortions caused by bladder/rectal conditions are generally small and subject-dependent. Local changes may be non-negligible within the CTV, thus proper management of filling status is warranted. Future work evaluating the impact of multiple models to accommodate for extreme status changes may be advantageous.

Technical Note: Harmonic analysis applied to MR image distortion fields specific to arbitrarily shaped volumes

PURPOSE

Magnetic resonance imaging is expected to play a more important role in radiation therapy given the recent developments in MR-guided technologies. MR images need to consistently show high spatial accuracy to facilitate RT-specific tasks such as treatment planning and in-room guidance. The present study investigates a new harmonic analysis method for the characterization of complex three-dimensional (3D) fields derived from MR images affected by system-related distortions.

METHODS

An interior Dirichlet problem based on solving the Laplace equation with boundary conditions (BCs) was formulated for the case of a 3D distortion field. The second-order boundary value problem (BVP) was solved using a finite elements method (FEM) for several quadratic geometries - that is, sphere, cylinder, cuboid, D-shaped, and ellipsoid. To stress-test the method and generalize it, the BVP was also solved for more complex surfaces such as a Reuleaux 9-gon and the MR imaging volume of a scanner featuring a high degree of surface irregularities. The BCs were formatted from reference experimental data collected with a linearity phantom featuring a volumetric grid structure. The method was validated by comparing the harmonic analysis results with the corresponding experimental reference fields.

RESULTS

The harmonic fields were found to be in good agreement with the baseline experimental data for all geometries investigated. In the case of quadratic domains, the percentage of sampling points with residual values larger than 1 mm was 0.5% and 0.2% for the axial components and vector magnitude, respectively. For the general case of a domain defined by the available MR imaging field of view, the reference data showed a peak distortion of about 1 mm and 79% of the sampling points carried a distortion magnitude larger than 1 mm (tolerance intrinsic to the experimental data). The upper limits of the residual values after comparison with the harmonic fields showed max and mean of 1.4 and 0.25 mm, respectively, with only 1.5% of sampling points exceeding 1 mm.

CONCLUSIONS

A novel harmonic analysis approach relying on finite element methods was introduced and validated for multiple volumes with surface shape functions ranging from simple to highly complex. Since a boundary value problem is solved the method requires input data from only the surface of the desired domain of interest. It is believed that the harmonic method will facilitate (a) the design of new phantoms dedicated for the quantitation of MR image distortions in large volumes and (b) an integrative approach of combining multiple imaging tests specific to radiotherapy into a single test object for routine imaging quality control.

A Robust Method for Estimating B0 Inhomogeneity Field in the Liver by Mitigating Fat Signals and Phase-Wrapping

We developed an optimized and robust method to estimate liver B0 field inhomogeneity for monitoring and correcting susceptibility-induced geometric distortion in magnetic resonance images for precision therapy. A triple-gradient-echo acquisition was optimized for the whole liver B0 field estimation within a single-exhale breath-hold scan on a 3 T scanner. To eliminate chemical-shift artifacts, fat signals were chosen in-phase between 2 echoes with an echo time difference (ΔTE) of 2.3 milliseconds. To avoid phase-wrapping, other 2 echoes provided a large field dynamic range (1/ΔTE) to cover the B0 field inhomogeneity. In addition, using high parallel imaging factor of 4 and a readout-bandwidth of 1955 Hz/pixel, an ∼18-second acquisition time for breath-held scans was achieved. A 2-step, 1-dimensional regularized method for the ΔB0 field map estimation was developed, tested and validated in phantom and patient studies. Our method was validated on a water phantom with fat components and air pockets; it yielded ΔB0-field maps that had no chemical-shift and phase-wrapping artifacts, and it had a <0.5 mm of geometric distortion near the air pockets. The ΔB0-field maps of the patients' abdominal regions were also free from phase-wrapping and chemical-shift artifacts. The maximum field inhomogeneity was found near the lung–liver interface, up to ∼300 Hz, resulting in ∼2 mm of distortions in anatomical images with a readout-bandwidth of 440 Hz/pixel. The field mapping method in the abdominal region is robust; it can be easily integrated in clinical workflow for patient-based quality control of magnetic resonance imaging geometric integrity.

A methodology to investigate the impact of image distortions on the radiation dose when using magnetic resonance images for planning

We developed a novel technique to study the impact of geometric distortion of magnetic resonance imaging (MRI) on intensity-modulated radiation therapy treatment planning. The measured 3D datasets of residual geometric distortion (a 1.5 T MRI component of an MRI linear accelerator system) was fitted with a second-order polynomial model to map the spatial dependence of geometric distortions. Then the geometric distortion model was applied to computed tomography (CT) image and structure data to simulate the distortion of MRI data and structures. Fourteen CT-based treatment plans were selected from patients treated for gastrointestinal, genitourinary, thoracic, head and neck, or spinal tumors. Plans based on the distorted CT and structure data were generated (as the distorted plans). Dose deviations of the distorted plans were calculated and compared with the original plans to study the dosimetric impact of MRI distortion. The MRI geometric distortion led to notable dose deviations in five of the 14 patients, causing loss of target coverage of up to 3.68% and dose deviations to organs at risk in three patients, increasing the mean dose to the chest wall by up to 6.19 Gy in a gastrointestinal patient, and increases the maximum dose to the lung by 5.17 Gy in a thoracic patient.

Geometric accuracy of the MR imaging techniques in the presence of motion

Magnetic Resonance Imaging (MRI) is increasingly being used for improving tumor delineation and tumor tracking in the presence of respiratory motion. The purpose of this work is to design and build an MR compatible motion platform and to use it for evaluating the geometric accuracy of MR imaging techniques during respiratory motion. The motion platform presented in this work is composed of a mobile base made up of a flat plate and four wheels. The mobile base is attached from one end and through a rigid rod to a synchrony motion table by Accuray^® placed at the end of the MRI table and from the other end to an elastic rod. The geometric accuracy was measured by placing a control point‐based phantom on top of the mobile base.

In‐house software module was used to automatically assess the geometric distortion. The blurring artifact was also assessed by measuring the Full Width Half Maximum (FWHM) of each control point. Our results were assessed for 50, 100, and 150 mm radial distances, with a mean geometric distortion during the superior–inferior motion of 0.27, 0.41, and 0.55 mm, respectively. Adding the anterior–posterior motion, the mean geometric distortions increased to 0.4, 0.6, and 0.8 mm. Blurring was observed during motion causing an increase in the FWHM of ≈30%. The platform presented in this work provides a valuable tool for the assessment of the geometric accuracy and blurring artifact for MR during motion. Although the main objective was to test the spatial accuracy of an MR system during motion, the modular aspect of the presented platform enables the use of any commercially available phantom for a full quality control of the MR system during motion.

Machine-Specific Magnetic Resonance Imaging Quality Control Procedures for Stereotactic Radiosurgery Treatment Planning

Purpose

Magnetic resonance (MR) images are necessary for accurate contouring of intracranial targets, determination of gross target volume and evaluation of organs at risk during stereotactic radiosurgery (SRS) treatment planning procedures. Many centers use magnetic resonance imaging (MRI) simulators or regular diagnostic MRI machines for SRS treatment planning; while both types of machine require two stages of quality control (QC), both machine- and patient-specific, before use for SRS, no accepted guidelines for such QC currently exist. This article describes appropriate machine-specific QC procedures for SRS applications.

Methods and materials

We describe the adaptation of American College of Radiology (ACR)-recommended QC tests using an ACR MRI phantom for SRS treatment planning. In addition, commercial Quasar MRID^3D and Quasar GRID^3D phantoms were used to evaluate the effects of static magnetic field (B₀) inhomogeneity, gradient nonlinearity, and a Leksell G frame (SRS frame) and its accessories on geometrical distortion in MR images.

Results

QC procedures found in-plane distortions (Maximum = 3.5 mm, Mean = 0.91 mm, Standard deviation = 0.67 mm, >2.5 mm (%) = 2) in X-direction (Maximum = 2.51 mm, Mean = 0.52 mm, Standard deviation = 0.39 mm, > 2.5 mm (%) = 0) and in Y-direction (Maximum = 13. 1 mm , Mean = 2.38 mm, Standard deviation = 2.45 mm, > 2.5 mm (%) = 34) in Z-direction and < 1 mm distortion at a head-sized region of interest. MR images acquired using a Leksell G frame and localization devices showed a mean absolute deviation of 2.3 mm from isocenter. The results of modified ACR tests were all within recommended limits, and baseline measurements have been defined for regular weekly QC tests.

Conclusions

With appropriate QC procedures in place, it is possible to routinely obtain clinically useful MR images suitable for SRS treatment planning purposes. MRI examination for SRS planning can benefit from the improved localization and planning possible with the superior image quality and soft tissue contrast achieved under optimal conditions.

MRI-Related Geometric Distortions in Stereotactic Radiotherapy Treatment Planning: Evaluation and Dosimetric Impact

In view of their superior soft tissue contrast compared to computed tomography, magnetic resonance images are commonly involved in stereotactic radiosurgery/radiotherapy applications for target delineation purposes. It is known, however, that magnetic resonance images are geometrically distorted, thus deteriorating dose delivery accuracy. The present work focuses on the assessment of geometric distortion inherent in magnetic resonance images used in stereotactic radiosurgery/radiotherapy treatment planning and attempts to quantitively evaluate the consequent impact on dose delivery. The geometric distortions for 3 clinical magnetic resonance protocols (at both 1.5 and 3.0 T) used for stereotactic radiosurgery/radiotherapy treatment planning were evaluated using a recently proposed phantom and methodology. Areas of increased distortion were identified at the edges of the imaged volume which was comparable to a brain scan. Although mean absolute distortion did not exceed 0.5 mm on any spatial axis, maximum detected control point disposition reached 2 mm. In an effort to establish what could be considered as acceptable geometric uncertainty, highly conformal plans were utilized to irradiate targets of different diameters (5-50 mm). The targets were mispositioned by 0.5 up to 3 mm, and dose–volume histograms and plan quality indices clinically used for plan evaluation and acceptance were derived and used to investigate the effect of geometrical uncertainty (distortion) on dose delivery accuracy and plan quality. The latter was found to be strongly dependent on target size. For targets less than 20 mm in diameter, a spatial disposition of the order of 1 mm could significantly affect (>5%) plan acceptance/quality indices. For targets with diameter greater than 2 cm, the corresponding disposition was found greater than 1.5 mm. Overall results of this work suggest that efficacy of stereotactic radiosurgery/radiotherapy applications could be compromised in case of very small targets lying distant from the scanner’s isocenter (eg, the periphery of the brain).

MR-guided radiation therapy: transformative technology and its role in the central nervous system

This review article describes advancement of magnetic resonance imaging technologies in radiation therapy planning, guidance, and adaptation of brain tumors. The potential for MR-guided radiation therapy to improve outcomes and the challenges in its adoption are discussed.

Magnetic resonance-only simulation and dose calculation in external beam radiation therapy: a feasibility study for pelvic cancers

BACKGROUND

The clinical feasibility of using pseudo-computed tomography (pCT) images derived from magnetic resonance (MR) images for external bean radiation therapy (EBRT) planning for prostate cancer patients has been well demonstrated. This paper investigates the feasibility of applying an MR-derived, pCT planning approach to additional types of cancer in the pelvis.

MATERIAL AND METHODS

Fifteen patients (five prostate cancer patients, five rectal cancer patients, and five gynecological cancer patients) receiving EBRT at Turku University Hospital (Turku, Finland) were included in the study. Images from an MRCAT (Magnetic Resonance for Calculating ATtenuation, Philips, Vantaa, Finland) pCT method were generated as a part of a clinical MR-simulation procedure. Dose calculation accuracy was assessed by comparing the pCT-based calculation with a CT-based calculation. In addition, the degree of geometric accuracy was studied.

RESULTS

The median relative difference of PTV mean dose between CT and pCT images was within 0.8% for all tumor types. When assessing the tumor site-specific accuracy, the median [range] relative dose differences to the PTV mean were 0.7 [-0.11;1.05]% for the prostate cases, 0.3 [-0.25;0.57]% for the rectal cases, and 0.09 [-0.69;0.25]% for the gynecological cancer cases. System-induced geometric distortion was measured to be less than 1 mm for all PTV volumes and the effect on the PTV median dose was less than 0.1%.

CONCLUSIONS

According to the comparison, using pCT for clinical EBRT planning and dose calculation in the three investigated types of pelvic cancers is feasible. Further studies are required to demonstrate the applicability to a larger cohort of patients.

Optimization of a novel large field of view distortion phantom for MR-only treatment planning

PURPOSE

MR-only treatment planning requires images of high geometric fidelity, particularly for large fields of view (FOV). However, the availability of large FOV distortion phantoms with analysis software is currently limited. This work sought to optimize a modular distortion phantom to accommodate multiple bore configurations and implement distortion characterization in a widely implementable solution.

METHOD AND MATERIALS

To determine candidate materials, 1.0 T MR and CT images were acquired of twelve urethane foam samples of various densities and strengths. Samples were precision-machined to accommodate 6 mm diameter paintballs used as landmarks. Final material candidates were selected by balancing strength, machinability, weight, and cost. Bore sizes and minimum aperture width resulting from couch position were tabulated from the literature (14 systems, 5 vendors). Bore geometry and couch position were simulated using MATLAB to generate machine-specific models to optimize the phantom build. Previously developed software for distortion characterization was modified for several magnet geometries (1.0 T, 1.5 T, 3.0 T), compared against previously published 1.0 T results, and integrated into the 3D Slicer application platform.

RESULTS

All foam samples provided sufficient MR image contrast with paintball landmarks. Urethane foam (compressive strength ∼1000 psi, density ~20 lb/ft³ ) was selected for its accurate machinability and weight characteristics. For smaller bores, a phantom version with the following parameters was used: 15 foam plates, 55 × 55 × 37.5 cm³ (L×W×H), 5,082 landmarks, and weight ~30 kg. To accommodate > 70 cm wide bores, an extended build used 20 plates spanning 55 × 55 × 50 cm³ with 7,497 landmarks and weight ~44 kg. Distortion characterization software was implemented as an external module into 3D Slicer's plugin framework and results agreed with the literature.

CONCLUSION

The design and implementation of a modular, extendable distortion phantom was optimized for several bore configurations. The phantom and analysis software will be available for multi-institutional collaborations and cross-validation trials to support MR-only planning.

New concept on an integrated interior magnetic resonance imaging and medical linear accelerator system for radiation therapy

Image guidance plays a critical role in radiotherapy. Currently, cone-beam computed tomography (CBCT) is routinely used in clinics for this purpose. While this modality can provide an attenuation image for therapeutic planning, low soft-tissue contrast affects the delineation of anatomical and pathological features. Efforts have recently been devoted to several MRI linear accelerator (LINAC) projects that lead to the successful combination of a full diagnostic MRI scanner with a radiotherapy machine. We present a new concept for the development of the MRI-LINAC system. Instead of combining a full MRI scanner with the LINAC platform, we propose using an interior MRI (iMRI) approach to image a specific region of interest (RoI) containing the radiation treatment target. While the conventional CBCT component still delivers a global image of the patient's anatomy, the iMRI offers local imaging of high soft-tissue contrast for tumor delineation. We describe a top-level system design for the integration of an iMRI component into an existing LINAC platform. We performed numerical analyses of the magnetic field for the iMRI to show potentially acceptable field properties in a spherical RoI with a diameter of 15 cm. This field could be shielded to a sufficiently low level around the LINAC region to avoid electromagnetic interference. Furthermore, we investigate the dosimetric impacts of this integration on the radiotherapy beam.

Gradient nonlinearity calibration and correction for a compact, asymmetric magnetic resonance imaging gradient system

Due to engineering limitations, the spatial encoding gradient fields in conventional magnetic resonance imaging cannot be perfectly linear and always contain higher-order, nonlinear components. If ignored during image reconstruction, gradient nonlinearity (GNL) manifests as image geometric distortion. Given an estimate of the GNL field, this distortion can be corrected to a degree proportional to the accuracy of the field estimate. The GNL of a gradient system is typically characterized using a spherical harmonic polynomial model with model coefficients obtained from electromagnetic simulation. Conventional whole-body gradient systems are symmetric in design; typically, only odd-order terms up to the 5th-order are required for GNL modeling. Recently, a high-performance, asymmetric gradient system was developed, which exhibits more complex GNL that requires higher-order terms including both odd- and even-orders for accurate modeling. This work characterizes the GNL of this system using an iterative calibration method and a fiducial phantom used in ADNI (Alzheimer's Disease Neuroimaging Initiative). The phantom was scanned at different locations inside the 26 cm diameter-spherical-volume of this gradient, and the positions of fiducials in the phantom were estimated. An iterative calibration procedure was utilized to identify the model coefficients that minimize the mean-squared-error between the true fiducial positions and the positions estimated from images corrected using these coefficients. To examine the effect of higher-order and even-order terms, this calibration was performed using spherical harmonic polynomial of different orders up to the 10th-order including even- and odd-order terms, or odd-order only. The results showed that the model coefficients of this gradient can be successfully estimated. The residual root-mean-squared-error after correction using up to the 10th-order coefficients was reduced to 0.36 mm, yielding spatial accuracy comparable to conventional whole-body gradients. The even-order terms were necessary for accurate GNL modeling. In addition, the calibrated coefficients improved image geometric accuracy compared with the simulation-based coefficients.

Consensus opinion on MRI simulation for external beam radiation treatment planning

AIM

To determine the levels at which consensus could be reached regarding general and site-specific principles of MRI simulation for offline MRI-aided external beam radiation treatment planning.

METHODS

A process inspired by the Delphi method was employed to determine levels of consensus using a series of questionnaires interspersed with controlled opinion feedback.

RESULTS

In general, full consensus was reached regarding general principles of MRI simulation. However, the level of consensus decreased when site-specific principles of MRI simulation were considered.

CONCLUSIONS

These results indicate variability in MRI simulation approaches that are largely explained by the use of MRI in combination with CT.

Distortion inherent to magnetic resonance imaging can lead to geometric miss in radiosurgery planning

PURPOSE

Anatomic distortion is present in all magnetic resonance imaging (MRI) data because of nonlinearity of gradient fields; it measures up to several millimeters. We evaluated the potential for uncorrected MRI to lead to geometric miss of the target volume in stereotactic radiosurgery (SRS).

METHODS AND MATERIALS

Twenty-eight SRS cases were studied retrospectively. MRI scans were corrected for gradient nonlinearity distortion in 3 dimensions, and gross tumor volumes (GTVs) were contoured. The manufacturer-specified distortion field was then reapplied to GTV masks to allow measurement of GTV displacement in uncorrected images. The uncorrected GTV was used for SRS planning, and the dose received by the true (corrected) GTV was measured.

RESULTS

Median displacement of the GTV resulting from gradient distortion was 1.2 mm (interquartile range, 0.1-2.3 mm), with a minimum of 0 mm and a maximum of 3.9 mm. Eight of the 28 cases met a priori criteria for "geometric miss."

CONCLUSIONS

Although MRI distortion is often subtle on visual inspection, there is a significant clinical impact of this distortion on SRS planning. Distortion-corrected MRI should uniformly be used for intracranial radiosurgery planning because uncorrected MRI can lead to potential geometric miss.

Technical Note: Characterization and correction of gradient nonlinearity induced distortion on a 1.0 T open bore MR-SIM

PURPOSE

Distortions in magnetic resonance imaging (MRI) compromise spatial fidelity, potentially impacting delineation and dose calculation. We characterized 2D and 3D large field of view (FOV), sequence-independent distortion at various positions in a 1.0 T high-field open MR simulator (MR-SIM) to implement correction maps for MRI treatment planning.

METHODS

A 36 × 43 × 2 cm(3) phantom with 255 known landmarks (∼1 mm(3)) was scanned using 1.0 T high-field open MR-SIM at isocenter in the transverse, sagittal, and coronal axes, and a 465 × 350 × 168 mm(3) 3D phantom was scanned by stepping in the superior-inferior direction in three overlapping positions to achieve a total 465 × 350 × 400 mm(3) sampled FOV yielding >13 800 landmarks (3D Gradient-Echo, TE/TR/α = 5.54 ms/30 ms/28°, voxel size = 1 × 1 × 2 mm(3)). A binary template (reference) was generated from a phantom schematic. An automated program converted MR images to binary via masking, thresholding, and testing for connectivity to identify landmarks. Distortion maps were generated by centroid mapping. Images were corrected via warping with inverse distortion maps, and temporal stability was assessed.

RESULTS

Over the sampled FOV, non-negligible residual gradient distortions existed as close as 9.5 cm from isocenter, with a maximum distortion of 7.4 mm as close as 23 cm from isocenter. Over six months, average gradient distortions were -0.07 ± 1.10 mm and 0.10 ± 1.10 mm in the x and y directions for the transverse plane, 0.03 ± 0.64 and -0.09 ± 0.70 mm in the sagittal plane, and 0.4 ± 1.16 and 0.04 ± 0.40 mm in the coronal plane. After implementing 3D correction maps, distortions were reduced to <1 pixel width (1 mm) for all voxels up to 25 cm from magnet isocenter.

CONCLUSIONS

Inherent distortion due to gradient nonlinearity was found to be non-negligible even with vendor corrections applied, and further corrections are required to obtain 1 mm accuracy for large FOVs. Statistical analysis of temporal stability shows that sequence independent distortion maps are consistent within six months of characterization.