MR-guidance--a clinical study to evaluate a shuttle- based MR-linac connection to provide MR-guided radiotherapy

Compliance of volunteers in a fully-enclosed patient rotation system for MR-guided radiation therapy: a prospective study

BACKGROUND

Particle therapy makes a noteworthy contribution in the treatment of tumor diseases. In order to be able to irradiate from different angles, usually expensive, complex and large gantries are used. Instead rotating the beam via a gantry, the patient itself might be rotated. Here we present tolerance and compliance of volunteers for a fully-enclosed patient rotation system in a clinical magnetic resonance (MR)-scanner for potential use in MR-guided radiotherapy, conducted within a prospective evaluation study.

METHODS

A patient rotation system was used to simulate and perform magnetic resonance imaging (MRI)-examinations with 50 volunteers without an oncological question. For 20 participants, the MR-examination within the bore was simulated by introducing realistic MRI noise, whereas 30 participants received an examination with image acquisition. Initially, body parameters and claustrophobia were assessed. The subjects were then rotated to different angles for simulation (0°, 45°, 90°, 180°) and imaging (0°, 70°, 90°, 110°). At each angle, anxiety and motion sickness were assessed using a 6-item State-Trait-Anxiety-Inventory (STAI-6) and a modified Motion Sickness Assessment Questionnaire (MSAQ). In addition, general areas of discomfort were evaluated.

RESULTS

Out of 50 subjects, three (6%) subjects terminated the study prematurely. One subject dropped out during simulation due to nausea while rotating to 45°. During imaging, further two subjects dropped out due to shoulder pain from positioning at 90° and 110°, respectively. The average result for claustrophobia (0 = no claustrophobia to 4 = extreme claustrophobia) was none to light claustrophobia (average score: simulation 0.64 ± 0.33, imaging 0.51 ± 0.39). The mean anxiety scores (0% = no anxiety to 100% = maximal anxiety) were 11.04% (simulation) and 15.82% (imaging). Mean motion sickness scores (0% = no motion sickness to 100% = maximal motion sickness) of 3.5% (simulation) and 6.76% (imaging) were obtained across all participants.

CONCLUSION

Our study proves the feasibility of horizontal rotation in a fully-enclosed rotation system within an MR-scanner. Anxiety scores were low and motion sickness was only a minor influence. Both anxiety and motion sickness showed no angular dependency. Further optimizations with regard to immobilization in the rotation device may increase subject comfort.

Markerless liver online adaptive stereotactic radiotherapy: feasibility analysisCervantes

Objective. Radio-opaque markers are recommended for image-guided radiotherapy in liver stereotactic ablative radiotherapy (SABR), but their implantation is invasive. We evaluate in thisin-silicostudy the feasibility of cone-beam computed tomography-guided stereotactic online-adaptive radiotherapy (CBCT-STAR) to propagate the target volumes without implanting radio-opaque markers and assess its consequence on the margin that should be used in that context.Approach. An emulator of a CBCT-STAR-dedicated treatment planning system was used to generate plans for 32 liver SABR patients. Three target volume propagation strategies were compared, analysing the volume difference between the GTVPropagatedand the GTVConventional, the vector lengths between their centres of mass (lCoM), and the 95th percentile of the Hausdorff distance between these two volumes (HD95). These propagation strategies were: (1) structure-guided deformable registration with deformable GTV propagation; (2) rigid registration with rigid GTV propagation; and (3) image-guided deformable registration with rigid GTV propagation. Adaptive margin calculation integrated propagation errors, while interfraction position errors were removed. Scheduled plans (PlanNon-adaptive) and daily-adapted plans (PlanAdaptive) were compared for each treatment fraction.Main results.The image-guided deformable registration with rigid GTV propagation was the best propagation strategy regarding tolCoM(mean: 4.3 +/- 2.1 mm), HD95 (mean 4.8 +/- 3.2 mm) and volume preservation between GTVPropagatedand GTVConventional. This resulted in a planning target volume (PTV) margin increase (+69.1% in volume on average). Online adaptation (PlanAdaptive) reduced the violation rate of the most important dose constraints ('priority 1 constraints', 4.2 versus 0.9%, respectively;p< 0.001) and even improved target volume coverage compared to non-adaptive plans (PlanNon-adaptive).Significance. Markerless CBCT-STAR for liver tumours is feasible using Image-guided deformable registration with rigid GTV propagation. Despite the cost in terms of PTV volumes, daily adaptation reduces constraints violation and restores target volumes coverage.

Millimeter wave-based patient setup verification and motion tracking during radiotherapy

BACKGROUND

Position verification and motion monitoring are critical for safe and precise radiotherapy (RT). Existing approaches to these tasks based on visible light or x-ray are suboptimal either because they cannot penetrate obstructions to the patient's skin or introduce additional radiation exposure. The low-cost mmWave radar is an ideal solution for these tasks as it can monitor patient position and motion continuously throughout the treatment delivery.

PURPOSE

To develop and validate frequency-modulated continuous wave (FMCW) mmWave radars for position verification and motion tracking during RT delivery.

METHODS

A 77 GHz FMCW mmWave module was used in this study. Chirp Z Transform-based (CZT) algorithm was developed to process the intermediate frequency (IF) signals. Absolute distances to flat Solid Water slabs and human shape phantoms were measured. The accuracy of absolute distance and relative displacement were evaluated.

RESULTS

Without obstruction, mmWave based on the CZT algorithm was able to detect absolute distance within 1 mm for a Solid Water slab that simulated the reflectivity of the human body. Through obstructive materials, the mmWave device was able to detect absolute distance within 5 mm in the worst case and within 3.5 mm in most cases. The CZT algorithm significantly improved the accuracy of absolute distance measurement compared with Fast Fourier Transform (FFT) algorithm and was able to achieve submillimeter displacement accuracy with and without obstructions. The surface-to-skin distance (SSD) measurement accuracy was within 8 mm in the anterior of the phantom.

CONCLUSIONS

With the CZT signal processing algorithm, the mmWave radar is able to measure the absolute distance to a flat surface within 1 mm. But the absolute distance measurement to a human shape phantom is as large as 8 mm at some angles. Further improvement is necessary to improve the accuracy of SSD measurement to uneven surfaces by the mmWave radar.

Clinical Workflow of Cone Beam Computer Tomography-Based Daily Online Adaptive Radiotherapy with Offline Magnetic Resonance Guidance: The Modular Adaptive Radiotherapy System (MARS)

PURPOSE

The Ethos (Varian Medical Systems) radiotherapy device combines semi-automated anatomy detection and plan generation for cone beam computer tomography (CBCT)-based daily online adaptive radiotherapy (oART). However, CBCT offers less soft tissue contrast than magnetic resonance imaging (MRI). This work aims to present the clinical workflow of CBCT-based oART with shuttle-based offline MR guidance.

METHODS

From February to November 2023, 31 patients underwent radiotherapy on the Ethos (Varian, Palo Alto, CA, USA) system with machine learning (ML)-supported daily oART. Moreover, patients received weekly MRI in treatment position, which was utilized for daily plan adaptation, via a shuttle-based system. Initial and adapted treatment plans were generated using the Ethos treatment planning system. Patient clinical data, fractional session times (MRI + shuttle transport + positioning, adaptation, QA, RT delivery) and plan selection were assessed for all fractions in all patients.

RESULTS

In total, 737 oART fractions were applied and 118 MRIs for offline MR guidance were acquired. Primary sites of tumors were prostate (n = 16), lung (n = 7), cervix (n = 5), bladder (n = 1) and endometrium (n = 2). The treatment was completed in all patients. The median MRI acquisition time including shuttle transport and positioning to initiation of the Ethos adaptive session was 53.6 min (IQR 46.5-63.4). The median total treatment time without MRI was 30.7 min (IQR 24.7-39.2). Separately, median adaptation, plan QA and RT times were 24.3 min (IQR 18.6-32.2), 0.4 min (IQR 0.3-1,0) and 5.3 min (IQR 4.5-6.7), respectively. The adapted plan was chosen over the scheduled plan in 97.7% of cases.

CONCLUSION

This study describes the first workflow to date of a CBCT-based oART combined with a shuttle-based offline approach for MR guidance. The oART duration times reported resemble the range shown by previous publications for first clinical experiences with the Ethos system.

Prospective validation of diffusion-weighted MRI as a biomarker of tumor response and oncologic outcomes in head and neck cancer: Results from an observational biomarker pre-qualification study

PURPOSE

To determine DWI parameters associated with tumor response and oncologic outcomes in head and neck (HNC) patients treated with radiotherapy (RT).

METHODS

HNC patients in a prospective study were included. Patients had MRIs pre-, mid-, and post-RT completion. We used T2-weighted sequences for tumor segmentation which were co-registered to respective DWIs for extraction of apparent diffusion coefficient (ADC) measurements. Treatment response was assessed at mid- and post-RT and was defined as: complete response (CR) vs. non-complete response (non-CR). The Mann-Whitney U test was used to compare ADC between CR and non-CR. Recursive partitioning analysis (RPA) was performed to identify ADC threshold associated with relapse. Cox proportional hazards models were done for clinical vs. clinical and imaging parameters and internal validation was done using bootstrapping technique.

RESULTS

Eighty-one patients were included. Median follow-up was 31 months. For patients with post-RT CR, there was a significant increase in mean ADC at mid-RT compared to baseline ((1.8 ± 0.29) × 10-3 mm2/s vs. (1.37 ± 0.22) × 10-3 mm2/s, p < 0.0001), while patients with non-CR had no significant increase (p > 0.05). RPA identified GTV-P delta (Δ)ADCmean < 7% at mid-RT as the most significant parameter associated with worse LC and RFS (p = 0.01). Uni- and multi-variable analysis showed that GTV-P ΔADCmean at mid-RT ≥ 7% was significantly associated with better LC and RFS. The addition of ΔADCmean significantly improved the c-indices of LC and RFS models compared with standard clinical variables (0.85 vs. 0.77 and 0.74 vs. 0.68 for LC and RFS, respectively, p < 0.0001 for both).

CONCLUSION

ΔADCmean at mid-RT is a strong predictor of oncologic outcomes in HNC. Patients with no significant increase of primary tumor ADC at mid-RT are at high risk of disease relapse.

Comprehensive Analysis of Set-Up Gain of 6-Dimensional Cone-Beam CT Correction Method in Radiotherapy for Head and Neck and Brain Tumors

This study quantitatively analyzed the gain of the six-dimensional (6D) cone-beam CT (CBCT) correction method compared with the conventional set-up method in 60 patients who underwent radiation treatment of head and neck and brain tumors. The correction gain of CBCT was calculated for the translational and rotational motion components separately and in combination to evaluate the individual and overall effects of these motion components. Using a statistical simulation mimicking the actual set-up correction process, the effective gain of periodic CBCT correction during the entire treatment fraction was analyzed by target size and CBCT correction period under two different correction scenarios: translation alone and full 6D corrections. From the analyses performed in this study, the gain of CBCT correction was quantitatively determined for each situation, and the appropriate CBCT correction strategy was suggested based on treatment purpose and target size.

Treatment-integrated imaging, radiomics, and personalised radiotherapy: the future is at hand

Since the introduction of computed tomography for planning purposes in the 1970s, we have been observing a continuous development of different imaging methods in radiotherapy. The current achievements of imaging technologies in radiotherapy enable more than just improvement of accuracy on the planning stage. Through integrating imaging with treatment machines, they allow advanced control methods of dose delivery during the treatment. This article reviews how the integration of existing and novel forms of imaging changes radiotherapy and how these advances can allow a more individualised approach to cancer therapy. We believe that the significant challenge for the next decade is the continued integration of a range of different imaging devices into linear accelerators. These imaging modalities should show intra-fraction changes in body morphology and inter-fraction metabolic changes. As the use of these more advanced, integrated machines grows, radiotherapy delivery will become more accurate, thus resulting in better clinical outcomes: higher cure rates with fewer side effects.

Image-guided Adaptive Radiotherapy for Bladder Cancer

Technological advancement has facilitated patient-specific radiotherapy in bladder cancer. This has been made possible by developments in image-guided radiotherapy (IGRT). Particularly transformative has been the integration of volumetric imaging into the workflow. The ability to visualise the bladder target using cone beam computed tomography and magnetic resonance imaging initially assisted with determining the magnitude of inter- and intra-fraction target change. It has led to greater confidence in ascertaining true anatomy at each fraction. The increased certainty of dose delivered to the bladder has permitted the safe reduction of planning target volume margins. IGRT has therefore improved target coverage with a reduction in integral dose to the surrounding tissue. Use of IGRT to feed back into plan and dose delivery optimisation according to the anatomy of the day has enabled adaptive radiotherapy bladder solutions. Here we undertake a review of the stepwise developments underpinning IGRT and adaptive radiotherapy strategies for external beam bladder cancer radiotherapy. We present the evidence in accordance with the framework for systematic clinical evaluation of technical innovations in radiation oncology (R-IDEAL).

[Magnetic-resonance-guided radiotherapy : The beginning of a new era in radiation oncology?]

CLINICAL ISSUE

Image-guided radiotherapy (IGRT) using X‑rays and cone-beam computed tomography (CT) has fostered precision radiotherapy. However, inter- and intrafractional variations of target volume position and organs at risk still limit target volume dose and sparing of radiosensitive organs at risk.

METHODOLOGICAL INNOVATIONS

Hybrid machines directly combining linear accelerators and magnetic resonance (MR) imaging allow for live imaging during radiotherapy.

PERFORMANCE

Besides highly improved soft tissue contrast, MR-linacs enable online, on-table adaptive radiotherapy. Thus, adaptation of the treatment plan to the anatomy of the day, dose escalation and superior sparing of organs at risk become possible.

ACHIEVEMENTS

This article summarizes the underlying intention for the development of MR-guided radiotherapy, technical innovations and challenges as well as the current state-of-the-art. Potential clinical benefits and future developments are discussed.

PRACTICAL RECOMMENDATIONS

Increasing availability of MR imaging at linear accelerators calls for the ability to review and interpret MR images. Therefore, close collaborations of diagnostic radiologists and radiation oncologists are mandatory to foster this fascinating technique.

Longitudinal acquisition repeatability of MRI radiomics features: An ACR MRI phantom study on two MRI scanners using a 3D T1W TSE sequence

PURPOSE

The purpose of this study was to quantitatively assess the longitudinal acquisition repeatability of MRI radiomics features in a three-dimensional (3D) T1-weighted (T1W) TSE sequence via a well-controlled prospective phantom study.

METHODS

Thirty consecutive daily datasets of an ACR-MRI phantom were acquired on two 1.5T MRI simulators using a 3D T1W TSE sequence. Images were blindly segmented by two observers. Post-acquisition processing was minimized but an intensity discretization (fixed bin size of 25). One hundred and one radiomics features (shape n = 12; first order n = 16; texture n = 73) were extracted. Longitudinal repeatability of each feature was evaluated by Pearson correlation and coefficient of variance (CV_68% ). Interobserver feature value agreement was also quantified using intraclass correlation coefficient (ICC) and Bland-Altman analysis. A most repeatable radiomics feature set on both scanners was determined by feature coefficient of variance (CV_68% <5%), ICC (>0.75), and the ratio of the interobserver difference to the interobserver mean δ<5%.

RESULTS

No trend of radiomics feature value changed with time. Longitudinal feature repeatability CV_68% ranged 0.01-38.60% (mean/median: 12.5%/9.9%), and 0.01-40.47%, (8.49%/7.34%) on the scanners A and B. Shape features exhibited significantly better repeatability than first-order and texture features (all P < 0.01). Significant longitudinal repeatability difference was observed in texture features (P < 0.001) between the two scanners, but not in shape and first-order features (P > 0.30). First-order and texture features had smaller interobserver-dependent variation than acquisition-dependent variation. They also showed good interobserver agreement on both scanners (A:ICC = 0.80 ± 0.23; B:ICC = 0.80 ± 0.22), independent of acquisition repeatability. The repeatable radiomics features in common on both scanners, including 12 shape features, 0 first-order features, and 3 texture features, were determined as the most repeatable MRI radiomics feature set.

CONCLUSIONS

Radiomics features exhibited heterogeneous longitudinal repeatability, while the shape features were the most repeatable, in this phantom study with a 3D T1W TSE acquisition. The most repeatable radiomics feature set derived in this study should be helpful for the selection of reliable radiomics features in the future clinical use.

MR-guided radiotherapy of moving targets

INTRODUCTION

Hybrid magnetic resonance (MR) linear accelerators (MR-Linacs) for radiotherapy allow for the visualization and tracking of moving target volumes during the entire treatment. This makes gated treatments possible, decreasing the irradiated volumes and thus sparing healthy tissue from unnecessary radiation dose. Conventionally, tumors that are subject to respiration motion are treated by irradiating the entire area of potential target presence (internal target volume, ITV). This study presents three patient cases (lung, adrenal gland, and liver tumors) treated with gated MR-guided radiotherapy and compares the treatment plans retrospectively with conventional ITV plans.

MATERIALS AND METHODS

The gross tumor volume was delineated on MR and computed tomography (CT) images of the patients, and MR-Linac treatment plans were generated using additional clinical and planning target volume margins. The motion of the gross tumor volume was evaluated on two-dimensional cine-MRI images during the entire MR-Linac treatment. Based on the motion analysis, standard ITV-based plans were retrospectively created and compared by means of irradiated target volumes and dose-volume parameters.

RESULTS

For the MR-Linac plans, the irradiated treatment volumes were reduced by an average of 62% across the three cases, and for one case the ITV-based target volume would have overlapped with a critical organ. Target volume coverage was much better and the lung and adrenal MR-Linac plans revealed superior sparing of the organs at risks thanks to gated treatments.

CONCLUSION

Dosimetrically beneficial treatment plans with promising clinical outcomes can be applied when using gated MR-guided radiotherapy. Future studies will reveal which patients will benefit most from this technique. To utilize the full potential of online adaptive, individualized MR-guided therapy, the close collaboration of radio-oncology and radiology is needed.

Low-dose cone-beam CT (LD-CBCT) reconstruction for image-guided radiation therapy (IGRT) by three-dimensional dual-dictionary learning

BACKGROUND

To develop a low-dose cone beam CT (LD-CBCT) reconstruction method named simultaneous algebraic reconstruction technique and dual-dictionary learning (SART-DDL) joint algorithm for image guided radiation therapy (IGRT) and evaluate its imaging quality and clinical application ability.

METHODS

In this retrospective study, 62 CBCT image sets from February 2018 to July 2018 at west china hospital were randomly collected from 42 head and neck patients (mean [standard deviation] age, 49.7 [11.4] years, 12 females and 30 males). All image sets were retrospectively reconstructed by SART-DDL (resultant D-CBCT image sets) with 18% less clinical raw projections. Reconstruction quality was evaluated by quantitative parameters compared with SART and Total Variation minimization (SART-TV) joint reconstruction algorithm with paired t test. Five-grade subjective grading evaluations were done by two oncologists in a blind manner compared with clinically used Feldkamp-Davis-Kress algorithm CBCT images (resultant F-CBCT image sets) and the grading results were compared by paired Wilcoxon rank test. Registration results between D-CBCT and F-CBCT were compared. D-CBCT image geometry fidelity was tested.

RESULTS

The mean peak signal to noise ratio of D-CBCT was 1.7 dB higher than SART-TV reconstructions (P < .001, SART-DDL vs SART-TV, 36.36 ± 0.55 dB vs 34.68 ± 0.28 dB). All D-CBCT images were recognized as clinically acceptable without significant difference with F-CBCT in subjective grading (P > .05). In clinical registration, the maximum translational and rotational difference was 1.8 mm and 1.7 degree respectively. The horizontal, vertical and sagittal geometry fidelity of D-CBCT were acceptable.

CONCLUSIONS

The image quality, geometry fidelity and clinical application ability of D-CBCT are comparable to that of the F-CBCT for head-and-neck patients with 18% less projections by SART-DDL.

Exploring MR regression patterns in rectal cancer during neoadjuvant radiochemotherapy with daily T2- and diffusion-weighted MRI

Background

To date, only limited magnetic resonance imaging (MRI) data are available concerning tumor regression during neoadjuvant radiochemotherapy (RCT) of rectal cancer patients, which is a prerequisite for adaptive radiotherapy (RT) concepts. This exploratory study prospectively evaluated daily fractional MRI during neoadjuvant treatment to analyze the predictive value of MR biomarkers for treatment response.

Methods

Locally advanced rectal cancer patients were examined with daily MRI during neoadjuvant RCT. Contouring of the tumor volume was performed for each MRI scan by using T2- and diffusion-weighted-imaging (DWI)-sequences. The daily apparent-diffusion coefficient (ADC) was calculated. Volumetric and functional tumor changes during RCT were analyzed and correlated with the pathological response after surgical resection.

Results

In total, 171 MRI scans of eight patients were analyzed regarding anatomical and functional dynamics during RCT. Pathological complete response (pCR) could be achieved in four patients, and four patients had a pathological partial response (pPR) following neoadjuvant treatment. T2- and DWI-based volumetry proved to be statistically significant in terms of therapeutic response, and volumetric thresholds at week two and week four during RCT were defined for the prediction of pCR. In contrast, the average tumor ADC values widely overlapped between both response groups during RCT and appeared inadequate to predict treatment response in our patient cohort.

Conclusion

This prospective exploratory study supports the hypothesis that MRI may be able to predict pCR of rectal cancers early during neoadjuvant RCT. Our data therefore provide a useful template to tailor future MR-guided adaptive treatment concepts.

Towards a generalised development of synthetic CT images and assessment of their dosimetric accuracy

Background: The interest in generating "synthetic computed tomography (CT) images" from magnetic resonance (MR) images has been increasing over the past years due to advances in MR guidance for radiotherapy. A variety of methods for synthetic CT creation have been developed, from simple bulk density assignment to complex machine learning algorithms.Material and methods: In this study, we present a general method to determine simplistic synthetic CTs and evaluate them according to their dosimetric accuracy. It separates the requirements on the MR image and the associated calculation effort to generate a synthetic CT. To evaluate the significance of the dosimetric accuracy under realistic conditions, clinically common uncertainties including position shifts and Hounsfield lookup table (HLUT) errors were simulated. To illustrate our approach, we first translated CT images from a test set of six pelvic cancer patients to relative electron density (ED) via a clinical HLUT. For each patient, seven simplified ED images (simED) were generated at different levels of complexity, ranging from one to four tissue classes. Then, dose distributions optimised on the reference ED image and the simEDs were compared to each other in terms of gamma pass rates (2 mm/2% criteria) and dose volume metrics.Results: For our test set, best results were obtained for simEDs with four tissue classes representing fat, soft tissue, air, and bone. For this simED, gamma pass rates of 99.95% (range: 99.72-100%) were achieved. The decrease in accuracy from ED simplification was smaller in this case than the influence of the uncertainty scenarios on the reference image, both for gamma pass rates and dose volume metrics.Conclusions: The presented workflow helps to determine the required complexity of synthetic CTs with respect to their dosimetric accuracy. The investigated cases showed potential simplifications, based on which the synthetic CT generation could be faster and more reproducible.

First prospective clinical evaluation of feasibility and patient acceptance of magnetic resonance-guided radiotherapy in Germany

PURPOSE

Magnetic resonance-guided radiotherapy (MRgRT) has recently been introduced in our institution. As MRgRT requires high patient compliance compared to conventional techniques and can be associated with prolonged treatment times, feasibility and patient tolerance were prospectively assessed using patient-reported outcome questionnaires (PRO-Q).

MATERIALS AND METHODS

Forty-three patients were enrolled in a prospective observational study and treated with MRgRT on a low-field hybrid Magnetic Resonance Linear Accelerator system (MR-Linac) between April 2018 and April 2019. For assistance in gated breath-hold delivery using cine-MRI, a video feedback system was installed. PRO-Qs consisted of questions on MR-related complaints and also assessed aspects of active patient participation.

RESULTS

The most commonly treated anatomic sites were nodal metastases and liver lesions. The mean treatment time was 34 min with a mean beam-on time of 2:17 min. Gated stereotactic body radiotherapy (SBRT) was applied in 47% of all patients. Overall, patients scored MRgRT as positive or at least tolerable in the PRO‑Q. Almost two thirds of patients (65%) complained about at least one item of the PRO‑Q (score ≥4), mainly concerning coldness, paresthesia, and uncomfortable positioning. All patients reported high levels of satisfaction with their active role using the video feedback system in breath-hold delivery.

CONCLUSION

MRgRT was successfully implemented in our clinic and well tolerated by all patients, despite MR-related complaints and complaints about uncomfortable immobilization. Prospective clinical studies are in development for further evaluation of MRgRT and for quantification of the benefit of MR-guided on-table adaptive radiotherapy.

A fast volumetric 4D-MRI with sub-second frame rate for abdominal motion monitoring and characterization in MRI-guided radiotherapy

Background

To propose a fast volumetric 4D-MRI based on 3D pulse sequence acquisition for abdominal motion monitoring and characterization in MRI-guided radiotherapy (MRgRT).

Methods

A 3D spoiled gradient echo sequence volumetric interpolated breath-hold examination (VIBE) [repetition time/echo time (TR/TE) =0.53/1.57 ms, flip-angle =5°, receiver bandwidth (RBW) =1,400 Hz/voxel] based 4D-MRI acquisition, accelerated by 4-fold controlled aliasing in parallel imaging results in higher acceleration (CAIPIRINHA), named CAIPIRINHA-VIBE 4D-MRI, was implemented on a 1.5T MRI simulator (MR-sim) and applied for abdominal imaging of nine healthy volunteers under free breathing. One hundred and forty-four dynamics of the entire abdomen volume (56 slices), in total 8,064 (144×56) images with a voxel size of 2.7×2.7×4.0 mm³, were acquired in 89 s for 4D-MRI. This CAIPIRINHA-VIBE 4D-MRI was qualitatively compared with a 2D half-Fourier acquisition single-shot turbo spin-echo (2D-HASTE) based 4D-MRI. The motions of liver dome, kidney and spleen were analyzed using the CAIPIRINHA-VIBE 4D-MRI data. The kidney motion was quantitatively characterized in terms of motion range and the correlations between left and right kidneys.

Results

CAIPIRINHA-VIBE 4D-MRI was successfully conducted in all subjects. CAIPIRINHA-VIBE 4D-MRI exhibited much higher effective volumetric temporal resolution (0.615 vs. ~5 s/volume) and better reconstructed volume consistency than 2D-HASTE 4D-MRI. CAIPIRINHA-VIBE 4D-MRI was able to characterize the respiratory motion of abdominal organs simultaneously in three orthogonal directions, and could potentially be used for whole abdomen deformable motion tracking. Renal motion range was most pronounced in superior-inferior (SI) direction (L: 10.03±2.65 mm; R: 10.38±2.80 mm), significantly larger (P<0.001) than that in anterior-posterior (AP) and the least in left-right (LR) directions. Right kidney had significantly larger mobility (4.18±2.19 vs. 2.32±1.34 mm, P=0.045) than left kidney in AP, but not in LR and SI directions. The Pearson correlation coefficients r between left and right kidney motion were 0.5063 (P=0.164), 0.6624 (P=0.052) and 0.5752 (P=0.105) in LR, AP and SI correspondingly. The correlation of renal motion in SI and AP was found significant in right kidney (r=0.843, P=0.004) but not in left kidney (r=0.467, P=0.205).

Conclusions

A fast volumetric 4D-MRI was implemented for abdominal motion monitoring in MRgRT. A sub-second volumetric temporal resolution of 0.615 s, covering the entire abdomen, was demonstrated for respiratory motion monitoring and characterization. This technique holds potentials for MRgRT applications.

A pilot study of highly accelerated 3D MRI in the head and neck position verification for MR-guided radiotherapy

Background

To evaluate the performance of a highly accelerated 3D MRI on inter-fractional positional measurement for MR-guided radiotherapy (MRgRT) in the head and neck (HN).

Methods

Fourteen healthy volunteers received 159 scans on a 1.5 T MR-sim to simulate MRgRT fractions. MRI acquisition included a high-resolution (HQI-MRI, voxel-size =1.05×1.05×1.05 mm³, duration =5 min) and a highly-accelerated low-resolution (true-LQI-MRI, acceleration-factor =9, voxel-size =1.4×1.4×1.4 mm³, duration =86 s) T1w spin-echo sequence (TR/TE =420/7.2 ms). The first session HQI-MRI was used as the reference to mimic planning MRI. Other HQI-MRI was also retrospectively down-sampled in K-space and GRAPPA reconstructed to generate pseudo-LQI-MRI. Inter-sessional positional shift calculated from HQI-MRI, true-LQI-MRI and pseudo-LQI-MRI rigidly registering to the reference were analyzed and compared in the overall HN and the sub-regions of brain, nasopharynx, oropharynx and hypopharynx.

Results

The calculated SD of systematic errors (Σ) from HQI-MRI/pseudo-LQI-MRI/true-LQI-MRI images for overall HN were 1.11/1.14/1.08, 0.28/0.26/0.29, 0.43/0.44/0.60, and 0.77/0.79/0.74 mm for translation in LR, AP, SI and 3D, respectively; The corresponding RMS of random errors (σ) were 0.97/0.98/0.96, 0.28/0.27/0.26, 0.77/0.77/0.72, and 0.85/0.87/0.85 mm. For all sub-regions, brain showed the smallest Σ and σ in 3D. Other sub-regions showed direction-dependent error patterns, but the positioning results were consistent, independent of the datasets used for registration.

Conclusions

A highly-accelerated 3D-MRI could be used for MR-guided HN radiotherapy without compromising position verification accuracy.

MR-guidance in clinical reality: current treatment challenges and future perspectives

Magnetic Resonance-guided radiotherapy (MRgRT) marks the beginning of a new era. MR is a versatile and suitable imaging modality for radiotherapy, as it enables direct visualization of the tumor and the surrounding organs at risk. Moreover, MRgRT provides real-time imaging to characterize and eventually track anatomical motion. Nevertheless, the successful translation of new technologies into clinical practice remains challenging. To date, the initial availability of next-generation hybrid MR-linac (MRL) systems is still limited and therefore, the focus of the present preview was on the initial applicability in current clinical practice and on future perspectives of this new technology for different treatment sites.MRgRT can be considered a groundbreaking new technology that is capable of creating new perspectives towards an individualized, patient-oriented planning and treatment approach, especially due to the ability to use daily online adaptation strategies. Furthermore, MRL systems overcome the limitations of conventional image-guided radiotherapy, especially in soft tissue, where target and organs at risk need accurate definition. Nevertheless, some concerns remain regarding the additional time needed to re-optimize dose distributions online, the reliability of the gating and tracking procedures and the interpretation of functional MR imaging markers and their potential changes during the course of treatment. Due to its continuous technological improvement and rapid clinical large-scale application in several anatomical settings, further studies may confirm the potential disruptive role of MRgRT in the evolving oncological environment.

Potential of MRI in Radiotherapy Mediated by Small Conjugates and Nanosystems

Radiation therapy has made tremendous progress in oncology over the last decades due to advances in engineering and physical sciences in combination with better biochemical, genetic and molecular understanding of this disease. Local delivery of optimal radiation dose to a tumor, while sparing healthy surrounding tissues, remains a great challenge, especially in the proximity of vital organs. Therefore, imaging plays a key role in tumor staging, accurate target volume delineation, assessment of individual radiation resistance and even personalized dose prescription. From this point of view, radiotherapy might be one of the few therapeutic modalities that relies entirely on high-resolution imaging. Magnetic resonance imaging (MRI) with its superior soft-tissue resolution is already used in radiotherapy treatment planning complementing conventional computed tomography (CT). Development of systems integrating MRI and linear accelerators opens possibilities for simultaneous imaging and therapy, which in turn, generates the need for imaging probes with therapeutic components. In this review, we discuss the role of MRI in both external and internal radiotherapy focusing on the most important examples of contrast agents with combined therapeutic potential.

Assessment of positional reproducibility in the head and neck on a 1.5-T MR simulator for an offline MR-guided radiotherapy solution

Background

Recently, a shuttle-based offline magnetic resonance-guided radiotherapy (MRgRT) approach was proposed. This study aims to evaluate the positional reproducibility in the immobilized head and neck using a 1.5-T MR-simulator (MR-sim) on healthy volunteers.

Methods

A total of 159 scans of 14 healthy volunteers were conducted on a 1.5-T MR-sim with thermoplastic mask immobilization. MR images with isotropic 1.05³ mm³ voxel size were rigidly registered to the first scan based on fiducial, anatomical and gross positions. Mean and standard deviation of positional displacements in translation and rotation were assessed. Systematic error and random errors of positioning in the head and neck on the MR-sim were determined in the translation of, and in the rotation of roll, pitch and yaw.

Results

The systematic error (Σ) of translation in left-right (LR), anterior-posterior (AP) and superior-inferior (SI) direction was 0.57, 0.22 and 0.26 mm for fiducial displacement, 0.28, 0.10 and 0.52 mm for anatomical displacement, and 0.53, 0.22 and 0.49 mm for gross displacement, respectively. The random error (σ) in corresponding translation direction was 2.07, 0.54 and 1.32 mm for fiducial displacement, 1.34, 0.73 and 2.04 mm for anatomical displacement, and 2.24, 0.86 and 2.61 mm for gross displacement. The systematic error and random error of rotation were generally smaller than 1°.

Conclusions

Our results suggested that high gross positional reproducibility (<1 mm translational and <1° rotational systematic error) could be achieved on an MR-sim for the proposed offline MRgRT.

A review of plan library approaches in adaptive radiotherapy of bladder cancer

BACKGROUND

Large variations in the shape and size of the bladder volume are commonly observed in bladder cancer radiotherapy (RT). The clinical target volume (CTV) is therefore frequently inadequately treated and large isotropic margins are inappropriate in terms of dose to organs at risk (OAR); thereby making adaptive radiotherapy (ART) attractive for this tumour site. There are various methods of ART delivery, however, for bladder cancer, plan libraries are frequently used.

MATERIAL AND METHODS

A review of published studies on plan libraries for bladder cancer using four databases (Pubmed, Science Direct, Embase and Cochrane Library) was conducted. The endpoints selected were accuracy and feasibility of initiation of a plan library strategy into a RT department.

RESULTS

Twenty-four articles were included in this review. The majority of studies reported improvement in accuracy with 10 studies showing an improvement in planning target volume (PTV) and CTV coverage with plan libraries, some by up to 24%. Seventeen studies showed a dose reduction to OARs, particularly the small bowel V45Gy, V40Gy, V30Gy and V10Gy, and the rectal V30Gy. However, the occurrence of no suitable plan was reported in six studies, with three studies showing no significant difference between adaptive and non-adaptive strategies in terms of target coverage. In addition, inter-observer variability in plan selection appears to remain problematic. The additional resources, education and technology required for the initiation of plan library selection for bladder cancer may hinder its routine clinical implementation, with eight studies illustrating increased treatment time required.

CONCLUSIONS

While there is a growing body of evidence in support of plan libraries for bladder RT, many studies differed in their delivery approach. The advent of the clinical use of the MRI-linear accelerator will provide RT departments with the opportunity to consider daily online adaption for bladder cancer as an alternate to plan library approaches.

The need for, and implementation of, image guidance in radiation therapy

The introduction of image guidance in radiation therapy and its subsequent innovations have revolutionised the delivery of cancer treatment. Modern imaging systems can supplement and often replace the historical practice of relying on external landmarks and laser alignment systems. Rather than depending on markings on the patient's skin, image-guided radiation therapy (IGRT), using techniques such as computed tomography (CT), cone beam CT, MV on-board imaging (OBI), and kV OBI, allows the patient to be positioned based on the internal anatomy. These advances in technology have enabled more accurate delivery of radiation doses to anatomically complex and temporally changing tumour volumes, while simultaneously sparing surrounding healthy tissues. While these imaging modalities provide excellent bony anatomy image quality, magnetic resonance imaging (MRI) surpasses them in soft tissue image contrast for better visualisation and tracking of soft tissue tumours with no additional radiation dose to the patient. However, the introduction of MRI into a radiotherapy facility has a number of complications, including the influence of the magnetic field on the dose deposition, as well as the effects it can have on dosimetry systems. The development and introduction of these new IGRT techniques will be reviewed, and the benefits and disadvantages of each will be described.

Effect of region extraction and assigned mass-density values on the accuracy of dose calculation with magnetic resonance-based volumetric arc therapy planning

This study aimed to verify the validity of generating treatment plans for volumetric arc therapy (VMAT) for prostate cancer using magnetic resonance (MR) imaging with a dose calculation algorithm in Acuros XB (Eclipse version 13.6; Varian Medical Systems, Palo Alto, CA, USA) based on deterministically solving the linear Boltzmann transport equations. Four different classes were applied to prostate MR images: MR_W (all water equivalent); MR_W+B (water and bone); MR_S+B (soft tissue and bone); and MR_S+B+G (soft tissue, bone, and rectal gas). Each of these regions was assigned a mass density for calculating doses. The assigned mass-density values were then altered in three ways. Using initial planning and optimization parameters, MR-based VMAT plans were generated and compared with corresponding forward-calculated computed tomography-based plans for doses to the target volumes and organs at risk using dose-volume histograms and γ analyses. In the MR_W plans, the mean doses for TVs were overestimated by approximately 1.3%. The MR_W+B plans revealed reduced differences within 0.5%. Further segmentation (MR_S+B) did not result in substantial improvement. Dose deviations affected by the changes in the mass densities assigned to soft tissue were as small as approximately 1.0%, whereas larger deviations were revealed in bone and rectal gas, especially those with > 5% error. Assignment of accurate mass-density values acquired from MR images is needed for MR-based radiation treatment planning. Multiple MR sequences should be acquired for segmentation and mass-density conversion purposes. Segmented MR-based VMAT planning is feasible with a density assignment method using Acuros XB.

Surgical Navigation in Orthopedics: Workflow and System Review

Orthopedic surgery is a widely performed clinical procedure that deals with problems in relation to the bones, joints, and ligaments of the human body, such as musculoskeletal trauma, spine diseases, sports injuries, degenerative diseases, infections, tumors, and congenital disorders. Surgical navigation is generally recognized as the next generation technology of orthopedic surgery. The development of orthopedic navigation systems aims to analyze pre-, intra- and/or postoperative data in multiple modalities and provide an augmented reality 3-D visualization environment to improve clinical outcomes of surgical orthopedic procedures. This chapter investigates surgical navigation techniques and systems that are currently available in orthopedic procedures. In particular, optical tracking, electromagnetic localizers and stereoscopic vision, as well as commercialized orthopedic navigation systems are thoroughly discussed. Moreover, advances and development trends in orthopedic navigation are also discussed in this chapter. While current orthopedic navigation systems enable surgeons to make precise decisions in the operating room by integrating surgical planning, instrument tracking, and intraoperative imaging, it still remains an active research field which provides orthopedists with various technical disciplines, e.g., medical imaging, computer science, sensor technology, and robotics, to further develop current orthopedic navigation methods and systems.

MRI-guided lung SBRT: Present and future developments

Stereotactic body radiotherapy (SBRT) is rapidly becoming an alternative to surgery for the treatment of early-stage non-small cell lung cancer patients. Lung SBRT is administered in a hypo-fractionated, conformal manner, delivering high doses to the target. To avoid normal-tissue toxicity, it is crucial to limit the exposure of nearby healthy organs-at-risk (OAR). Current image-guided radiotherapy strategies for lung SBRT are mostly based on X-ray imaging modalities. Although still in its infancy, magnetic resonance imaging (MRI) guidance for lung SBRT is not exposure-limited and MRI promises to improve crucial soft-tissue contrast. Looking beyond anatomical imaging, functional MRI is expected to inform treatment decisions and adaptations in the future. This review summarises and discusses how MRI could be advantageous to the different links of the radiotherapy treatment chain for lung SBRT: diagnosis and staging, tumour and OAR delineation, treatment planning, and inter- or intrafractional motion management. Special emphasis is placed on a new generation of hybrid MRI treatment devices and their potential for real-time adaptive radiotherapy.

Evaluation of Dosimetric Robustness of Carbon Ion Boost Therapy for Anal Carcinoma

Purpose

The radiation therapy treatment outcome of human papillomavirus-negative anal carcinoma may be improved by the biological effectiveness of carbon ions. However, abdominal tissue motion can compromise the precision of carbon ion therapy. This work aims to evaluate the dosimetric feasibility of carbon ion boost (CIB) therapy for anal carcinoma.

Materials and Methods

An algorithm to generate computed tomographies based on daily magnetic resonance imaging data and deformable image registration was developed. By means of this algorithm, fractional computed tomography data for 54 treatment fractions for 3 different patients with anal carcinoma were derived. The dose for a sequential CIB (CIB_seq) treatment plan was recalculated on the fractional computed tomography data and accumulated over the number of fractions. The resulting dose distributions were compared to standard intensity-modulated radiation therapy treatment with an integrated photon boost.

Results

For the investigated patient cases, similar dosimetric results for CIB_seq treatment and for intensity-modulated radiation therapy with an integrated photon boost were found. For CIB_seq treatment, bladder-filling variation had the strongest influence on the dose distribution. However, the detrimental effects on the mean target dose remained below 1 Gy (RBE) as compared to photon therapy.

Conclusion

This study shows the dosimetric feasibility of CIB therapy for anal carcinoma for the first time and gives reason for clinical exploitation of the enhanced biological effect of carbon ions for patients with human papillomavirus-negative anal cancer.

Feasibility of MRI-only treatment planning for proton therapy in brain and prostate cancers: Dose calculation accuracy in substitute CT images

PURPOSE

Magnetic resonance imaging (MRI) is increasingly used for radiotherapy target delineation, image guidance, and treatment response monitoring. Recent studies have shown that an entire external x-ray radiotherapy treatment planning (RTP) workflow for brain tumor or prostate cancer patients based only on MRI reference images is feasible. This study aims to show that a MRI-only based RTP workflow is also feasible for proton beam therapy plans generated in MRI-based substitute computed tomography (sCT) images of the head and the pelvis.

METHODS

The sCTs were constructed for ten prostate cancer and ten brain tumor patients primarily by transforming the intensity values of in-phase MR images to Hounsfield units (HUs) with a dual model HU conversion technique to enable heterogeneous tissue representation. HU conversion models for the pelvis were adopted from previous studies, further extended in this study also for head MRI by generating anatomical site-specific conversion models (a new training data set of ten other brain patients). This study also evaluated two other types of simplified sCT: dual bulk density (for bone and water) and homogeneous (water only). For every clinical case, intensity modulated proton therapy (IMPT) plans robustly optimized in standard planning CTs were calculated in sCT for evaluation, and vice versa. Overall dose agreement was evaluated using dose-volume histogram parameters and 3D gamma criteria.

RESULTS

In heterogeneous sCTs, the mean absolute errors in HUs were 34 (soft tissues: 13, bones: 92) and 42 (soft tissues: 9, bones: 97) in the head and in the pelvis, respectively. The maximum absolute dose differences relative to CT in the brain tumor clinical target volume (CTV) were 1.4% for heterogeneous sCT, 1.8% for dual bulk sCT, and 8.9% for homogenous sCT. The corresponding maximum differences in the prostate CTV were 0.6%, 1.2%, and 3.6%, respectively. The percentages of dose points in the head and pelvis passing 1% and 1 mm gamma index criteria were over 91%, 85%, and 38% with heterogeneous, dual bulk, and homogeneous sCTs, respectively. There were no significant changes to gamma index pass rates for IMPT plans first optimized in CT and then calculated in heterogeneous sCT versus IMPT plans first optimized in heterogeneous sCT and then calculated on standard CT.

CONCLUSIONS

This study demonstrates that proton therapy dose calculations on heterogeneous sCTs are in good agreement with plans generated with standard planning CT. An MRI-only based RTP workflow is feasible in IMPT for brain tumors and prostate cancers.

Worst case optimization for interfractional motion mitigation in carbon ion therapy of pancreatic cancer

INTRODUCTION

The efficacy of radiation therapy treatments for pancreatic cancer is compromised by abdominal motion which limits the spatial accuracy for dose delivery - especially for particles. In this work we investigate the potential of worst case optimization for interfractional offline motion mitigation in carbon ion treatments of pancreatic cancer.

METHODS

We implement a worst case optimization algorithm that explicitly models the relative biological effectiveness of carbon ions during inverse planning. We perform a comparative treatment planning study for seven pancreatic cancer patients. Treatment plans that have been generated using worst case optimization are compared against (1) conventional intensity-modulated carbon ion therapy, (2) single field uniform dose carbon ion therapy, and (3) an ideal yet impractical scenario relying on daily re-planning. The dosimetric quality and robustness of the resulting treatment plans is evaluated using reconstructions of the daily delivered dose distributions on fractional control CTs.

RESULTS

Idealized daily re-planning consistently gives the best dosimetric results with regard to both target coverage and organ at risk sparing. The absolute reduction of D 95 within the gross tumor volume during fractional dose reconstruction is most pronounced for conventional intensity-modulated carbon ion therapy. Single field uniform dose optimization exhibits no substantial reduction for six of seven patients and values for D 95 for worst case optimization fall in between. The treated volume (D>95 % prescription dose) outside of the gross tumor volume is reduced by a factor of two by worst case optimization compared to conventional optimization and single field uniform dose optimization. Single field uniform dose optimization comes at an increased radiation exposure of normal tissues, e.g. ≈2 Gy (RBE) in the mean dose in the kidneys compared to conventional and worst case optimization and ≈4 Gy (RBE) in D 1 in the spinal cord compared to worst case optimization.

CONCLUSION

Interfractional motion substantially deteriorates dose distributions for carbon ion treatments of pancreatic cancer patients. Single field uniform dose optimization mitigates the negative influence of motion on target coverage at an increased radiation exposure of normal tissue. Worst case optimization enables an exploration of the trade-off between robust target coverage and organ at risk sparing during inverse treatment planning beyond margin concepts.

A software tool to automatically assure and report daily treatment deliveries by a cobalt-60 radiation therapy device

The aims of this study were to develop a method for automatic and immediate verification of treatment delivery after each treatment fraction in order to detect and correct errors, and to develop a comprehensive daily report which includes delivery verification results, daily image‐guided radiation therapy (IGRT) review, and information for weekly physics reviews. After systematically analyzing the requirements for treatment delivery verification and understanding the available information from a commercial MRI‐guided radiotherapy treatment machine, we designed a procedure to use 1) treatment plan files, 2) delivery log files, and 3) beam output information to verify the accuracy and completeness of each daily treatment delivery. The procedure verifies the correctness of delivered treatment plan parameters including beams, beam segments and, for each segment, the beam‐on time and MLC leaf positions. For each beam, composite primary fluence maps are calculated from the MLC leaf positions and segment beam‐on time. Error statistics are calculated on the fluence difference maps between the plan and the delivery. A daily treatment delivery report is designed to include all required information for IGRT and weekly physics reviews including the plan and treatment fraction information, daily beam output information, and the treatment delivery verification results. A computer program was developed to implement the proposed procedure of the automatic delivery verification and daily report generation for an MRI guided radiation therapy system. The program was clinically commissioned. Sensitivity was measured with simulated errors. The final version has been integrated into the commercial version of the treatment delivery system. The method automatically verifies the EBRT treatment deliveries and generates the daily treatment reports. Already in clinical use for over one year, it is useful to facilitate delivery error detection, and to expedite physician daily IGRT review and physicist weekly chart review.

PACS number(s): 87.55.km

The potential of MRI-guided online adaptive re-optimisation in radiotherapy of urinary bladder cancer

BACKGROUND AND PURPOSE

Adaptive radiotherapy (ART) using plan selection is being introduced clinically for bladder cancer, but the challenge of how to compensate for intra-fractional motion remains. The purpose of this study was to assess target coverage with respect to intra-fractional motion and the potential for normal tissue sparing in MRI-guided ART (MRIGART) using isotropic (MRIGARTiso), an-isotropic (MRIGARTanIso) and population-based margins (MRIGARTpop).

MATERIALS AND METHODS

Nine bladder cancer patients treated in a phase II trial of plan selection underwent 6-7 weekly repeat MRI series, each with volumetric scans acquired over a 10 min period. Adaptive re-planning on the 0 min MRI scans was performed using density override, simulating a hypo-fractionated schedule. Target coverage was evaluated on the 10 min scan to quantify the impact of intra-fractional motion.

RESULTS

MRIGARTanIso reduced the course-averaged PTV by median 304 cc compared to plan selection. Bladder shifts affected target coverage in individual fractions for all strategies. Two patients had a v95% of the bladder below 98% for MRIGARTiso. MRIGARTiso decreased the bowel V25 with 15-46 cc compared to MRIGARTpop.

CONCLUSION

Online re-optimised ART has a considerable normal tissue sparing potential. MRIGART with online corrections for target shift during a treatment fraction should be considered in ART for bladder cancer.

Review of potential improvements using MRI in the radiotherapy workflow

The goal of modern radiotherapy is to deliver a lethal amount of dose to tissue volumes that contain a significant amount of tumour cells while sparing surrounding unaffected or healthy tissue. Online image guided radiotherapy with stereotactic ultrasound, fiducial-based planar X-ray imaging or helical/conebeam CT has dramatically improved the precision of radiotherapy, with moving targets still posing some methodical problems regarding positioning. Therefore, requirements for precise target delineation and identification of functional body structures to be spared by high doses become more evident. The identification of areas of relatively radioresistant cells or areas of high tumor cell density is currently under development. This review outlines the state of the art of MRI integration into treatment planning and its importance in follow up and the quantification of biological effects. Finally the current state of the art of online imaging for patient positioning will be outlined and indications will be given what the potential of integrated radiotherapy/online MRI systems is.