Stereotactic body radiotherapy of central lung tumours using a 1.5 T MR-linac: First clinical experiences.

Background: MRI-guidance may aid better discrimination between Organs at Risk (OARs) and target volumes in proximity of the mediastinum. We report the first clinical experiences with Stereotactic Body Radiotherapy (SBRT) of (ultra)central lung tumours on a 1.5 T MR-linac. Materials and Methods: Patients with an (ultra)central lung tumour were selected for MR-linac based SBRT treatment. A T2-weighted 3D sequence MRI acquired during free breathing was used for daily plan adaption. Prior to each fraction, contours of Internal Target Volume (ITV) and OARs were deformably propagated and amended by a radiation oncologist. Inter-fractional changes in volumes and coverage of target volumes as well as doses in OARs were evaluated in offline and online treatment plans. Results: Ten patients were treated and completed 60 Gy in 8 or 12 fractions. In total 104 fractions were delivered. The median time in the treatment room was 41 min with a median beam-on time of 8.9 min. No grade ≥3 acute toxicity was observed. In two patients, the ITV significantly decreased during treatment (58 % and 37 %, respectively) due to tumour shrinkage. In the other patients, 81 % of online ITVs were within ±15 % of the volume of fraction 1. Comparison with the pre-treatment plan showed that ITV coverage of the online plan was similar in 52 % and improved in 34 % of cases. Adaptation to meet OAR constraints, led to decreased ITV coverage in 14 %. Conclusions: We describe the workflow for MR-guided Radiotherapy and the feasibility of using 1.5 T MR-linac for SBRT of (ultra) central lung tumours.

Dosimetric evaluation of off-axis fields and angular transmission for the 1.5 T MR-linac.

Objective.GPU-oriented Monte Carlo dose (GPUMCD) is a fast dose calculation algorithm used for treatment planning on the Unity MR-linac. Treatments for the MR-linac must be calculated quickly and accurately, and must account for two important MR-linac aspects: off-axis positions and angular transmission through the cryostat, couch and MR-coils. Therefore, the aim of this research is to quantify the system-related errors for GPUMCD calculations over the range of clinically-relevant field configurations and gantry angles.Approach.Dose profiles (crossline, inline and PDD) were measured and calculated for varying field sizes, off-axis positions and depths. Eleven different (off-axis) positions were included. The angular transmission was investigated by measuring and calculating the transmission for multiple angles, taking the cryostat, couch and coils into account.Main results.Differences between absolute point doses were found to be within 1.7% for field sizes 2 × 2 cm2and larger. The relative dose profiles in the crossline, inline and PDD direction illustrated maximum mean dose differences of 0.9pp, 0.8pp and 0.7pp ofDmaxin the central region for field sizes 2 × 2 cm2and larger. The 1 × 1 cm2field size showed larger dosimetric errors for absolute point doses and relative dose profiles. The maximum mean DTA in the penumbra was 0.7 mm. The mean difference in angular transmission ranged from -0.33% ± 0.60% to 0.27% ± 0.91% using three treatment machines. Additionally, 77.1%-93.7% of the datapoints remained within 1% transmission difference. The largest transmission differences were present at the edges of the table.Significance.This research showed that the GPUMCD algorithm provides reliable dose calculations with a low uncertainty for field sizes 2 × 2 cm2and larger, focusing on off-axis fields and angular transmission.

A formalism for reference dosimetry in photon beams in the presence of a magnetic field.

A generic formalism is proposed for reference dosimetry in the presence of a magnetic field. Besides the regular correction factors from the conventional reference dosimetry formalisms, two factors are used to take into account magnetic field effects: (1) a dose conversion factor to correct for the change in local dose distribution and (2) a correction of the reading of the dosimeter used for the reference dosimetry measurements. The formalism was applied to the Elekta MRI-Linac, for which the 1.5 T magnetic field is orthogonal to the 7 MV photon beam. For this setup at reference conditions it was shown that the dose decreases with increasing magnetic field strength. The reduction in local dose for a 1.5 T transverse field, compared to no field is 0.51% ± 0.03% at the reference point of 10 cm depth. The effect of the magnetic field on the reading of the dosimeter was measured for two waterproof ionization chambers types (PTW 30013 and IBA FC65-G) before and after multiple ramp-up and ramp-downs of the magnetic field. The chambers were aligned perpendicular and parallel to the magnetic field. The corrections of the readings of the perpendicularly aligned chambers were 0.967 ± 0.002 and 0.957 ± 0.002 for respectively the PTW and IBA ionization chambers. In the parallel alignment the corrections were small; 0.997 ± 0.001 and 1.002 ± 0.003 for the PTW and IBA chamber respectively. The change in reading due to the magnetic field can be measured by individual departments. The proposed formalism can be used to determine the correction factors needed to establish the absorbed dose in a magnetic field. It requires Monte Carlo simulations of the local dose and measurements of the response of the dosimeter. The formalism was successfully implemented for the MRI-Linac and is applicable for other field strengths and geometries.

Beam characterisation of the 1.5 T MRI-linac.

As a prerequisite for clinical treatments it was necessary to characterize the Elekta 1.5 T MRI-linac 7 MV FFF radiation beam. Following acceptance testing, beam characterization data were acquired with Semiflex 3D (PTW 31021), microDiamond (PTW 60019), and Farmer-type (PTW 30013 and IBA FC65-G) detectors in an Elekta 3D scanning water phantom and a PTW 1D water phantom. EBT3 Gafchromic film and ion chamber measurements in a buildup cap were also used. Special consideration was given to scan offsets, detector effective points of measurement and avoiding air gaps. Machine performance has been verified and the system satisfied the relevant beam requirements of IEC60976. Beam data were acquired for field sizes between 1 × 1 and 57 × 22 cm2. New techniques were developed to measure percentage depth dose (PDD) curves including the electron return effect at beam exit, which exhibits an electron-type practical range of 1.2 ± 0.1 cm. The Lorentz force acting on the secondary charged particles creates an asymmetry in the crossline profiles with an average shift of +0.24 cm. For a 10 × 10 cm2 beam, scatter from the cryostat contributes 1% of the dose at isocentre. This affects the relative output factors, scatter factors and beam profiles, both in-field and out-of-field. The average 20%-80% penumbral width measured for small fields with a microDiamond detector at 10 cm depth is 0.50 cm. MRI-linac penumbral widths are very similar to that of the Elekta Agility linac MLC, as is the near-surface dose PDD(0.2 cm) = 57%. The entrance surface dose is ∼36% of Dmax. Cryostat transmission is quantified for inclusion within the treatment planning system. As a result, the 1.5 T MRI-linac 7 MV FFF beam has been characterised for the first time and is suitable for clinical use. This was a key step towards the first clinical treatments with the MRI-linac, which were delivered at University Medical Center Utrecht in May 2017 (Raaymakers et al 2017 Phys. Med. Biol. 62 L41-50).

Spiraling contaminant electrons increase doses to surfaces outside the photon beam of an MRI-linac with a perpendicular magnetic field.

The transverse magnetic field of an MRI-linac sweeps contaminant electrons away from the radiation beam. Films oriented perpendicular to the magnetic field and 5 cm from the radiation beam edge show a projection of the divergent beam, indicating that contaminant electrons spiral along magnetic field lines and deposit dose on surfaces outside the primary beam perpendicular to the magnetic field. These spiraling contaminant electrons (SCE) could increase skin doses to protruding regions of the patient along the cranio-caudal axis. This study investigated doses from SCE for an MRI-linac comprising a 7 MV linac and a 1.5 T MRI scanner. Surface doses to films perpendicular to the magnetic field and 5 cm from the radiation beam edge showed increased dose within the projection of the primary beam, whereas films parallel to the magnetic field and 5 cm from the beam edge showed no region of increased dose. However, the dose from contaminant electrons is absorbed within a few millimeters. For large fields, the SCE dose is within the same order of magnitude as doses from scattered and leakage photons. Doses for both SCE and scattered photons decrease rapidly with decreasing beam size and increasing distance from the beam edge.

First patients treated with a 1.5 T MRI-Linac: clinical proof of concept of a high-precision, high-field MRI guided radiotherapy treatment.

The integration of 1.5 T MRI functionality with a radiotherapy linear accelerator (linac) has been pursued since 1999 by the UMC Utrecht in close collaboration with Elekta and Philips. The idea behind this integrated device is to offer unrivalled, online and real-time, soft-tissue visualization of the tumour and the surroundings for more precise radiation delivery. The proof of concept of this device was given in 2009 by demonstrating simultaneous irradiation and MR imaging on phantoms, since then the device has been further developed and commercialized by Elekta. The aim of this work is to demonstrate the clinical feasibility of online, high-precision, high-field MRI guidance of radiotherapy using the first clinical prototype MRI-Linac. Four patients with lumbar spine bone metastases were treated with a 3 or 5 beam step-and-shoot IMRT plan. The IMRT plan was created while the patient was on the treatment table and based on the online 1.5 T MR images; pre-treatment CT was deformably registered to the online MRI to obtain Hounsfield values. Bone metastases were chosen as the first site as these tumors can be clearly visualized on MRI and the surrounding spine bone can be detected on the integrated portal imager. This way the portal images served as an independent verification of the MRI based guidance to quantify the geometric precision of radiation delivery. Dosimetric accuracy was assessed post-treatment from phantom measurements with an ionization chamber and film. Absolute doses were found to be highly accurate, with deviations ranging from 0.0% to 1.7% in the isocenter. The geometrical, MRI based targeting as confirmed using portal images was better than 0.5 mm, ranging from 0.2 mm to 0.4 mm. In conclusion, high precision, high-field, 1.5 T MRI guided radiotherapy is clinically feasible.

Consequences of air around an ionization chamber: Are existing solid phantoms suitable for reference dosimetry on an MR-linac?

PURPOSE: A protocol for reference dosimetry for the MR-linac is under development. The 1.5 T magnetic field changes the mean path length of electrons in an air-filled ionization chamber but has little effect on the electron trajectories in a surrounding phantom. It is therefore necessary to correct the response of an ionization chamber for the influence of the magnetic field. Solid phantoms are used for dosimetry measurements on the MR-linac, but air is present between the chamber wall and phantom insert. This study aimed to determine if this air influences the ion chamber measurements on the MR-linac. The absolute response of the chamber and reproducibility of dosimetry measurements were assessed on an MR-linac in solid and water phantoms. The sensitivity of the chamber response to the distribution of air around the chamber was also investigated. METHODS: Measurements were performed on an MR-linac and replicated on a conventional linac for five chambers. The response of three waterproof chambers was measured with air and with water between the chamber and the insert to measure the influence of the air volume on absolute chamber response. The distribution of air around the chamber was varied indirectly by rotating each chamber about the longitudinal chamber axis in a solid phantom and a water phantom (waterproof chambers only) and measuring the angular dependence of the chamber response, and varied directly by displacing the chamber in the phantom insert using a paper shim positioned at different orientations between the chamber casing and the insert. RESULTS: The responses of the three waterproof chambers measured on the MR-linac were 0.7%-1.2% higher with water than air in the chamber insert. The responses of the chambers on the conventional linac changed by less than 0.3% when air in the insert was replaced with water. The angular dependence of the chambers ranged from 0.6% to 1.9% in the solid phantom on the MR-linac but was less than 0.5% in water on the MR-linac and less than 0.3% in the solid phantom on the conventional linac. Inserting a shim around the chamber induced changes of the chamber response in a magnetic field of up to 2.2%, but the change in chamber response on the conventional linac was less than 0.3%. CONCLUSIONS: The interaction between the magnetic field and secondary electrons in the air around the chamber reduces the charge collected from 0.7% to 1.2%. The large angular dependence of ion chambers measured in the plastic phantom in a magnetic field appears to arise from a change of air distribution as the chamber is moved within the insert, rather than an intrinsic isotropy of the chamber sensitivity to radiation. It is recommended that reference dosimetry measurements on the MR-linac can be performed only in water, rather than in existing plastic phantoms.