Technical note: MLC racking performance on the Elekta unity MRI-linac : MLC-tracking performance on the Elekta unity MRI-linac

Recently, multileaf collimator (MLC)-tracking has been technically and clinically demonstrated showing promising improvements of radiotherapy of mobile sites. Furthermore, magnetic resonance imaging (MRI)-guided treatments have shown to provide superior targetting performance due to on-line soft-tissue imaging. Hitherto, the combination of MLC-tracking and MRI has not been investigated using clinically released hardware. In this note we aim to describe the technical feasibilty of such a combination on a clinically operating MRI-linac. The MLC-tracking system is characterized by quantifying the latencies and geometric errors produced by the system. In order to reach optimization recommendations, the tracking system was first characterized using a quasi-ideal position sensor, isolating the performance of the MLC only. Subsequently, the analysis was repeated using real-time MRI as the positioning source for the MLC. For the isolated MLC, we found latencies of 20.67 ms and minimal overshooting behaviour. The latencies for MRI-guidance were 347.45 ms at 4 Hz imaging and 204 ms at 8 Hz. We showed that MLC-tracking on the Elekta Unity using integrated MRI is technically supported and feasible. The isolated analysis of the MLC demonstrated the negligible contribution of the MLC in MRI-guided tracking. The latency and geometric errors caused by the sampling properties of MRI exceed the MLC-related errors by several factors. Most gain for real-time MRI-based adaptive radiotherapy can therefore be realized by optimizing and accelerating the MRI acquisition process

Technical Note : Consistency of PTW30013 and FC65-G ion chamber magnetic field correction factors

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

Technical Note : Consistency of PTW30013 and FC65-G ion chamber magnetic field correction factors

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

Characterization of the first RF coil dedicated to 1.5 T MR guided radiotherapy

The purpose of this study is to investigate the attenuation characteristics of a novel radiofrequency (RF) coil, which is the first coil that is solely dedicated to MR guided radiotherapy with a 1.5 T MR-linac. Additionally, we investigated the impact of the treatment beam on the MRI performance of this RF coil. First, the attenuation characteristics of the RF coil were characterized. Second, we investigated the impact of the treatment beam on the MRI performance of the RF coil. We additionally demonstrated the ability of the anterior coil to attenuate returning electrons and thereby reducing the dose to the skin at the distal side of the treatment beam. Intensity modulated radiation therapy simulation of a clinically viable treatment plan for spinal bone metastasis shows a decrease of the dose to the planned tumor volume of 1.8% as a result of the MR coil around the patient. Ionization chamber and film measurements show that the anterior and posterior coil attenuate the beam homogeneously by 0.4% and 2.2%, respectively. The impact of the radiation resulted in a slight drop of the time-course signal-to-noise ratio and was dependent on imaging parameters. However, we could not observe any image artifacts resulting from this irradiation in any situation. In conclusion, the investigated MR-coil can be utilized for treatments with the 1.5 T-linac system. However, there is still room for improvement when considering both the dosimetric and imaging performance of the coil

3-Dimensional target coverage assessment for MRI guided esophageal cancer radiotherapy

Purpose: This study aimed to quantify the coverage probability for esophageal cancer radiotherapy as a function of a preset margin for online MR-guided and (CB)CT-guided radiotherapy. Methods: Thirty esophageal cancer patients underwent six T2-weighted MRI scans, 1 prior to treatment and 5 during neoadjuvant chemoradiotherapy at weekly intervals. Gross tumor volume (GTV) and clinical target volume (CTV) were delineated on each individual scan. Follow-up scans were rigidly aligned to the bony anatomy and to the clinical target volume itself, mimicking two online set-up correction strategies: a conventional CBCT-guided set-up and a MR-guided set-up, respectively. Geometric coverage probability of the propagated CTVs was assessed for both set-up strategies by expanding the reference CTV with an isotropic margin varying from 0 mm to 15 mm with an increment of 1 mm. Results: A margin of 10 mm could resolve the interfractional changes for 118 out of the 132 (89%) analyzed fractions when applying a bone-match registration, whereas the CTV was adequately covered in 123 (93%) fractions when the registration was directly performed at the CTV itself (soft-tissue registration). Closer analyses revealed that target coverage violation predominantly occurred for distal tumors near the junction and into the cardia. Conclusion: Online MR-guided soft-tissue registration protocols exhibited modest improvements of the geometric target coverage probability as compared to online CBCT-guided bone match protocols. Therefore, highly conformal target irradiation using online MR-guidance can only be achieved by implementing on-table adaptive workflows where new treatment plans are daily generated based on the anatomy of the day

Image guidance in radiation therapy for better cure of cancer

The key goal and main challenge of radiation therapy is the elimination of tumors without any concurring damages of the surrounding healthy tissues and organs. Radiation doses required to achieve sufficient cancer-cell kill exceed in most clinical situations the dose that can be tolerated by the healthy tissues, especially when large parts of the affected organ are irradiated. High-precision radiation oncology aims at optimizing tumor coverage, while sparing normal tissues. Medical imaging during the preparation phase, as well as in the treatment room for localization of the tumor and directing the beam, referred to as image-guided radiotherapy (IGRT), is the cornerstone of precision radiation oncology. Sophisticated high-resolution real-time IGRT using X-rays, computer tomography, magnetic resonance imaging, or ultrasound, enables delivery of high radiation doses to tumors without significant damage of healthy organs. IGRT is the most convincing success story of radiation oncology over the last decades, and it remains a major driving force of innovation, contributing to the development of personalized oncology, for example, through the use of real-time imaging biomarkers for individualized dose delivery

Correlation between functional imaging markers derived from diffusion-weighted MRI and F-18-FDG PET/CT in esophageal cancer

Objective Both the apparent diffusion coefficient (ADC) acquired by diffusion-weighted magnetic resonance imaging (DW-MRI) and the standardized uptake value (SUV), acquired by 18 F-fluorodeoxyglucose positron emission tomography/computed tomography (18 F-FDG PET/CT), are well-established functional parameters in cancer imaging. Currently, it is unclear whether these two markers provide complementary prognostic and predictive information in esophageal cancer. The aim of this study was to evaluate the correlation between ADC and SUV in patients with esophageal cancer. Materials and methods This prospective study included 76 patients with histologically proven esophageal cancer who underwent both DW-MRI and 18 F-FDG PET/CT examinations before treatment. The minimum and mean ADC values (ADC min and ADC mean) of the primary tumor were assessed on MRI. Similarly, the glucose metabolism was evaluated by the maximum and mean SUV (SUV max and SUV mean) in the same lesions on 18 F-FDG PET/CT images. Spearman's rank correlation coefficients were used to assess the correlation between tumor ADC and SUV values. Results The tumor ADC and SUV values as measures of cell density and glucose metabolism, respectively, showed negligible nonsignificant correlations (ADC min vs. SUV max: r=-0.087, P=0.457; ADC min vs. SUV mean: r=-0.105, P=0.369; ADC mean vs. SUV max: r=-0.099, P=0.349; ADC mean vs. SUV mean: r=-0.111, P=0.340). No differences in tumor ADC and SUV values were observed between the different histologic tumor types, stages, and differentiation grades. Conclusion This study indicates that tumor cellularity derived from DW-MRI and tumor metabolism measured by 18 F-FDG PET/CT are independent cellular phenomena in newly diagnosed esophageal cancer. Therefore, tumor ADC and SUV values may play complementary roles as imaging markers in the prediction of survival and evaluation of response to treatment in esophageal cancer

Conventional radical versus focal treatment for localised prostate cancer: a propensity score weighted comparison of 6-year tumour control

Background: For localised prostate cancer, focal therapy offers an organ-sparing alternative to radical treatments (radiotherapy or prostatectomy). Currently, there is no randomised comparative effectiveness data evaluating cancer control of both strategies. Methods: Following the eligibility criteria PSA &lt; 20 ng/mL, Gleason score ≤ 7 and T-stage ≤ T2c, we included 830 radical (440 radiotherapy, 390 prostatectomy) and 530 focal therapy (cryotherapy, high-intensity focused ultrasound or high-dose-rate brachytherapy) patients treated between 2005 and 2018 from multicentre registries in the Netherlands and the UK. A propensity score weighted (PSW) analysis was performed to compare failure-free survival (FFS), with failure defined as salvage treatment, metastatic disease, systemic treatment (androgen deprivation therapy or chemotherapy), or progression to watchful waiting. The secondary outcome was overall survival (OS). Median (IQR) follow-up in each cohort was 55 (28–83) and 62 (42–83) months, respectively. Results: At baseline, radical patients had higher PSA (10.3 versus 7.9) and higher-grade disease (31% ISUP 3 versus 11%) compared to focal patients. After PSW, all covariates were balanced (SMD &lt; 0.1). 6-year weighted FFS was higher after radical therapy (80.3%, 95% CI 73.9–87.3) than after focal therapy (72.8%, 95% CI 66.8–79.8) although not statistically significant (p = 0.1). 6-year weighted OS was significantly lower after radical therapy (93.4%, 95% CI 90.1–95.2 versus 97.5%, 95% CI 94–99.9; p = 0.02). When compared in a three-way analysis, focal and LRP patients had a higher risk of treatment failure than EBRT patients (p &lt; 0.001), but EBRT patients had a higher risk of mortality than focal patients (p = 0.008). Conclusions: Within the limitations of a cohort-based analysis in which residual confounders are likely to exist, we found no clinically relevant difference in cancer control conferred by focal therapy compared to radical therapy at 6 years.</p