IPEM topical report: guidance on the use of MRI for external beam radiotherapy treatment planning.

This document gives guidance for multidisciplinary teams within institutions setting up and using an MRI-guided radiotherapy (RT) treatment planning service. It has been written by a multidisciplinary working group from the Institute of Physics and Engineering in Medicine (IPEM). Guidance has come from the experience of the institutions represented in the IPEM working group, in consultation with other institutions, and where appropriate references are given for any relevant legislation, other guidance documentation and information in the literature. Guidance is only given for MRI acquired for external beam RT treatment planning in a CT-based workflow, i.e. when MRI is acquired and registered to CT with the purpose of aiding delineation of target or organ at risk volumes. MRI use for treatment response assessment, MRI-only RT and other RT treatment types such as brachytherapy and gamma radiosurgery are not considered within the scope of this document. The aim was to produce guidance that will be useful for institutions who are setting up and using a dedicated MR scanner for RT (referred to as an MR-sim) and those who will have limited time on an MR scanner potentially managed outside of the RT department, often by radiology. Although not specifically covered in this document, there is an increase in the use of hybrid MRI-linac systems worldwide and brief comments are included to highlight any crossover with the early implementation of this technology. In this document, advice is given on introducing a RT workload onto a non-RT-dedicated MR scanner, as well as planning for installation of an MR scanner dedicated for RT. Next, practical guidance is given on the following, in the context of RT planning: training and education for all staff working in and around an MR scanner; RT patient set-up on an MR scanner; MRI sequence optimisation for RT purposes; commissioning and quality assurance (QA) to be performed on an MR scanner; and MRI to CT registration, including commissioning and QA.

Measurements of human tolerance to horizontal rotation within an MRI scanner: Towards gantry-free radiation therapy.

INTRODUCTION: Recent advances in image guidance and adaptive radiotherapy could enable gantry-free radiotherapy using patient rotation. Gantry-free radiotherapy could substantially reduce the cost of radiotherapy systems and facilities. MRI guidance complements a gantry-free approach because of its ability to visualise soft tissue deformation during rotation. A potential barrier to gantry-free radiotherapy is patient acceptability, especially when combined with MRI. This study investigates human experiences of horizontal rotation within an MRI scanner. METHODS: Ten healthy human participants and nine participants previously treated with radiotherapy were rotated within an MRI scanner. Participants' anxiety and motion sickness was assessed before being rotated in 45-degree increments and paused, representing a multi-field intensity-modulated radiotherapy treatment. An MR image was acquired at each 45-degree angle. Following imaging, anxiety and motion sickness were re-assessed, followed by a comfort questionnaire and exit interview. The significance of the differences in anxiety and motion sickness pre- versus post-imaging was assessed using Wilcoxon signed-rank tests. Content analysis was performed on exit interview transcripts. RESULTS: Eight of ten healthy and eight of nine patient participants completed the imaging session. Mean anxiety scores before and after imaging were 7.9/100 and 11.8/100, respectively (P = 0.26), and mean motion sickness scores were 5.3/100 and 13.7/100, respectively (P = 0.02). Most participants indicated likely acceptance of rotation if MRI were to be used in a hypothetical treatment. Physical discomfort was reported to be the biggest concern. CONCLUSIONS: Horizontal rotation within an MRI scanner was acceptable for most (17/19) participants.

Imaging performance of a high-field in-line magnetic resonance imaging linear accelerator with a patient rotation system for fixed-gantry radiotherapy.

This paper describes the imaging performance of a high-field in-line MRI linear accelerator with a patient rotation system in-situ. Signal quality was quantified using signal-to-noise ratio (SNR) and RF uniformity maps. B0-field inhomogeneity was assessed using magnetic field mapping. SNR was evaluated with various entries into the Faraday cage which were required for extended couch translations. SNR varied between 103 and 87 across PRS rotation angles. Maximum B0-field inhomogeneity corresponded to 0.7 mm of geometric distortion. A 45 × 55 cm2 aperture allowed PRS translation with no reduction in SNR. Imaging performance with the PRS in-situ was found to be acceptable.

Multicenter evaluation of MRI-based radiomic features: A phantom study.

INTRODUCTION: This work describes the development of a novel radiomics phantom designed for magnetic resonance imaging (MRI) that can be used in a multicenter setting. The purpose of this study is to assess the stability and reproducibility of MRI-based radiomic features using this phantom across different MRI scanners. METHODS & MATERIALS: A set of phantoms were three-dimensional (3D) printed using MRI visible materials. One set of phantoms were imaged on seven MRI scanners and one was imaged on one MRI scanner. Radiomics analysis of the phantoms, which included first-order features, shape and texture features was performed. Intraclass correlation coefficient (ICC) was used to assess the stability of radiomic features across eight scanners and the reproducibility of two printed models on one scanner. Coefficient of variation (COV) was used to assess the reproducibility of radiomics measurements in the phantom on a single scanner. RESULTS: The phantom models provide sufficient signal-to-noise and contrast in all the tumor models permitting robust automatic segmentation. During a 12-month period of monitoring, the phantom material was stable with T1 and T2 of 150.7 ± 6.7 ms and 56.1 ± 3.9 ms, respectively. Of all the radiomic features computed, 34 of 69 had COV < 10%. Features from first-order statistics were the most robust in stability across the eight scanners with eight of 12 (67%) having high stability. About 29 of 50 (58%) texture features had high stability and no shape features had high stability features across the eight scanners. CONCLUSION: A novel MRI radiomics phantom has been developed to assess the reproducibility and stability of MRI-based radiomic features across multiple institutions. The variation in radiomic feature stability demonstrates the need for caution when interpreting these features for clinical studies.

Geometric distortion characterization and correction for the 1.0 T Australian MRI-linac system using an inverse electromagnetic method.

PURPOSE: The magnetic resonance imaging (MRI)-Linac system combines a MRI scanner and a linear accelerator (Linac) to realize real-time localization and adaptive radiotherapy for tumors. Given that the Australian MRI-Linac system has a 30-cm diameter of spherical volume (DSV) with a shimmed homogeneity of ±4.05 parts per million (ppm), a gradient nonlinearity (GNL) of <5% can only be assured within 15 cm from the system's isocenter. GNL increases from the isocenter and escalates close to and outside of the edge of the DSV. Gradient nonlinearity can cause large geometric distortions, which may provide inaccurate tumor localization and potentially degrade the radiotherapy treatment. In this study, we aimed to characterize and correct the geometric distortions both inside and outside of the DSV. METHODS: On the basis of phantom measurements, an inverse electromagnetic (EM) method was developed to reconstitute the virtual current density distribution that could generate gradient fields. The obtained virtual EM source was capable of characterizing the GNL field both inside and outside of the DSV. With the use of this GNL field information, our recently developed "GNL-encoding" reconstruction method was applied to correct the distortions implemented in the k-space domain. RESULTS: Both phantom and in vivo human images were used to validate the proposed method. The results showed that the maximal displacements within an imaging volume of 30 cm × 30 cm × 30 cm after using the fifth-order spherical harmonic (SH) method and the proposed method were 6.1 ± 0.6 mm and 1.8 ± 0.6 mm, respectively. Compared with the fifth-order SH-based method, the new solution decreased the percentage of markers (within an imaging volume of 30 cm × 30 cm × 30 cm) with ≥1.5-mm distortions from 6.3% to 1.3%, indicating substantially improved geometric accuracy. CONCLUSIONS: The experimental results indicated that the proposed method could provide substantially improved geometric accuracy for the region outside of the DSV, when comparing with the fifth-order SH-based method.

Tissue mimicking materials for imaging and therapy phantoms: a review.

Tissue mimicking materials (TMMs), typically contained within phantoms, have been used for many decades in both imaging and therapeutic applications. This review investigates the specifications that are typically being used in development of the latest TMMs. The imaging modalities that have been investigated focus around CT, mammography, SPECT, PET, MRI and ultrasound. Therapeutic applications discussed within the review include radiotherapy, thermal therapy and surgical applications. A number of modalities were not reviewed including optical spectroscopy, optical imaging and planar x-rays. The emergence of image guided interventions and multimodality imaging have placed an increasing demand on the number of specifications on the latest TMMs. Material specification standards are available in some imaging areas such as ultrasound. It is recommended that this should be replicated for other imaging and therapeutic modalities. Materials used within phantoms have been reviewed for a series of imaging and therapeutic applications with the potential to become a testbed for cross-fertilization of materials across modalities. Deformation, texture, multimodality imaging and perfusion are common themes that are currently under development.

First experimental investigation of simultaneously tracking two independently moving targets on an MRI-linac using real-time MRI and MLC tracking.

PURPOSE: High quality radiotherapy is challenging in cases where multiple targets with independent motion are simultaneously treated. A real-time tumor tracking system that can simultaneously account for the motion of two targets was developed and characterized. METHODS: The multitarget tracking system was implemented on a magnetic resonance imaging (MRI)-linac and utilized multi-leaf collimator (MLC) tracking to adapt the radiation beam to phantom targets reproducing motion with prostate and lung motion traces. Multitarget tracking consisted of three stages: (a) pretreatment aperture segmentation where the treatment aperture was divided into segments corresponding to each target, (b) MR imaging where the positions of the two targets were localized, and (c) MLC tracking where an updated treatment aperture was calculated. Electronic portal images (EPID) acquired during irradiation were analyzed to characterize geometric uncertainty and tracking latency. RESULTS: Multitarget MLC tracking effectively accounted for the motion of both targets during treatment. The root-mean-square error between the centers of the targets and the centers of the corresponding MLC leaves were reduced from 5.5 mm without tracking to 2.7 mm with tracking for lung motion traces and reduced from 4.2 to 1.4 mm for prostate motion traces. The end-to-end latency of tracking was measured to be 328 ± 44 ms. CONCLUSIONS: We have demonstrated the first experimental implementation of MLC tracking for multiple targets having independent motion. This technology takes advantage of the imaging capabilities of MRI-linacs and would allow treatment margins to be reduced in cases where multiple targets are simultaneously treated.

Development of multi-purpose 3D printed phantoms for MRI.

This work describes the development and application of 3D printed MRI phantoms. Unlike traditional phantoms these test objects are made from solid materials which can be imaged directly without filling. The models were manufactured using both MRI visible and invisible materials. The MRI visible materials were imaged on a 3T system to quantify their T 1 and T 2 properties and CT to quantify the electron density. Three phantoms are described: a distortion phantom was imaged on an open bore MRI system to assess distortion over a 30 cm field-of-view; a solid tumour model was imaged using a motion simulator and compared to a standard water phantom to assess reduction in artefacts; finally, a test object created for textural analysis was evaluated on two 3T systems and reproducibility was assessed. Material 1 was the main material used in all phantom models and has a T 1 and T 2 of 152.3 ± 3.7 ms and 56.7 ± 2.5 ms and a CT density of 127.9 HU. Material 2 had a CT density of 115.1 HU and material 3 had a T 1 and T 2 of 149.5 ± 2.9 ms and 68.8 ± 7.8 ms and CT density of 15.3 HU. Image tests demonstrated the suitability and advantage of each phantom over more traditional versions: a high density set of control points enabled a comprehensive measurement of geometric accuracy; sufficient signal with a reduction in artefact was observed in the motion phantom, and the texture model provided reproducible measurements with an ICC > 0.9 for over 76% of texture features. Three different phantoms have been successfully manufactured and used to demonstrate the application of 3D printable materials for MRI phantoms.

Technical Note: The first live treatment on a 1.0 Tesla inline MRI-linac.

PURPOSE: This work describes the first live imaging and radiation delivery performed on a prototype 1.0 T inline MRI-Linac system in a rat brain tumor model, which was conducted on 29 January 2019. METHODS: A human scale 1.0 T MRI-Linac was adapted to be suitable for animal studies via a specially constructed open 6-channel receiver radiofrequency (RF) coil. A Fischer rat injected with 9L glioma cells in the right hemisphere was imaged and irradiated at day 11 post surgery as part of a larger cohort survival study. The rat was anesthetized and positioned at the iscocenter of the MRI-Linac. Imaging was used to localize the brain and confirm the presence of a tumor following the administration of a gadolinium nanoparticle contrast agent. A single dose of 10 Gy was delivered using a 2.25 cm × 2.90 cm radiation field covering the whole brain and verified with radiosensitive film in situ. Real-time imaging was used throughout the irradiation period to monitor the animal and target position. RESULTS: The signal-to-noise ratio (SNR) measured in the rat brain was 38. Postcontrast imaging was able to demonstrate a tumor of 5 mm diameter in the upper right hemisphere of the brain approximately 45 min after administration of the nanoparticles. The radiation beam had no impact on SNR and images at the rate of 2 Hz were effective in monitoring both respiration and intrafractional motion. In vivo film dosimetry confirmed the intended dose delivery. The total procedure time was 35 min. CONCLUSIONS: We have successfully used MRI guidance to localize and subsequently deliver a radiation field to the whole brain of a rat with a right hemispheric tumor. Real-time imaging during beam on was of sufficient quality to monitor breathing and perform exception gating of the treatment. This represents the first live use of a high field inline MRI-Linac.

IPEM Topical Report: A 2018 IPEM survey of MRI use for external beam radiotherapy treatment planning in the UK.

The benefits of integrating MRI into the radiotherapy pathway are well published, however there is little consensus in guidance on how to commission or implement its use. With a view to developing consensus guidelines for the use of MRI in external beam radiotherapy (EBRT) treatment planning in the UK, a survey was undertaken by an Institute of Physics and Engineering in Medicine (IPEM) working-party to assess the current landscape of MRI use in EBRT in the UK. A multi-disciplinary working-party developed a survey to understand current practice using MRI for EBRT treatment planning; investigate how MRI is currently used and managed; and identify knowledge gaps. The survey was distributed electronically to radiotherapy service managers and physics leads in 71 UK radiotherapy (RT) departments (all NHS and private groups). The survey response rate was 87% overall, with 89% of NHS and 75% of private centres responding. All responding centres include EBRT in some RT pathways: 94% using Picture Archiving and Communication System (PACS) images potentially acquired without any input from RT departments, and 69% had some form of MRI access for planning EBRT. Most centres reporting direct access use a radiology scanner within the same hospital in dedicated (26%) or non-dedicated (52%) RT scanning sessions. Only two centres reported having dedicated RT MRI scanners in the UK, lower than reported in other countries. Six percent of radiotherapy patients in England (data not publically available outside of England) have MRI as part of their treatment, which again is lower than reported elsewhere. Although a substantial number of centres acquire MRI scans for treatment planning purposes, most centres acquire less than five patient scans per month for each treatment site. Commissioning and quality assurance of both image registration and MRI scanners was found to be variable across the UK. In addition, staffing models and training given to different staff groups varied considerably across the UK, reflecting the current lack of national guidelines. The primary barriers reported to MRI implementation in EBRT planning included costs (e.g. lack of a national tariff for planning MRI), lack of MRI access and/or capacity within hospitals. Despite these challenges, significant interest remains in increasing MRI-assisted EBRT planning over the next five years.

3D printed phantoms mimicking cortical bone for the assessment of ultrashort echo time magnetic resonance imaging.

PURPOSE: Human cortical bone has a rapid T2∗ decay, and it can be visualized using ultrashort echo time (UTE) techniques in magnetic resonance imaging (MRI). These sequences operate at the limits of gradient and transmit-receive signal performance. Development of multicompartment anthropomorphic phantoms that can mimic human cortical bone can assist with quality assurance and optimization of UTE sequences. The aims of this study were to (a) characterize the MRI signal properties of a photopolymer resin that can be 3D printed, (b) develop multicompartment phantoms based on the resin, and (c) demonstrate the feasibility of using these phantoms to mimic human anatomy in the assessment of UTE sequences. METHODS: A photopolymer resin (Prismlab China Ltd, Shanghai, China) was imaged on a 3 Tesla MRI system (Siemens Skyra) to characterize its MRI properties with emphasis on T2∗ signal and longevity. Two anthropomorphic phantoms, using the 3D printed resin to simulate skeletal anatomy, were developed and imaged using UTE sequences. A skull phantom was developed and used to assess the feasibility of using the resin to develop a complex model with realistic morphological human characteristics. A tibia model was also developed to assess the suitability of the resin at mimicking a simple multicompartment anatomical model and imaged using a three-dimensional UTE sequence (PETRA). Image quality measurements of signal-to-noise ratio (SNR) and contrast factor were calculated and these were compared to in vivo values. RESULTS: The T2∗ and T1 (mean ± standard deviation) of the photopolymer resin was found to be 411 ± 19 µs and 74.39 ± 13.88 ms, respectively, and demonstrated no statistically significant change during 4 months of monitoring. The resin had a similar T2∗ decay to human cortical bone; however, had lower T1 properties. The bone water concentration of the resin was 59% relative to an external water reference phantom, and this was higher than in vivo values reported for human cortical bone. The multicompartment anthropomorphic head phantom was successfully produced and able to simulate realistic air cavities, bony anatomy, and soft tissue. Image quality assessment in the tibia phantom using the PETRA sequence showed the suitability of the resin to mimic human anatomy with high SNR and contrast making it suitable for tissue segmentation. CONCLUSIONS: A solid resin material, which can be 3D printed, has been found to have similar magnetic resonance signal properties to human cortical bone. Phantoms replicating skeletal anatomy were successfully produced using this resin and demonstrated their use for image quality and segmentation assessment of ultrashort echo time sequences.

An assessment of set up position for MRI scanning for the purposes of rectal cancer radiotherapy treatment planning.

INTRODUCTION: A magnetic resonance (MR) scanner for radiotherapy treatment simulation was commissioned in our department in June 2013. Practical set up and MR image quality trade-offs using a variety of patient positions and immobilisation devices routinely used in the treatment planning of rectal cancer patients were considered. The study also aimed to investigate the MR compatibility of the device materials with a focus on temperature changes during routine clinical examinations. METHODS: Ten volunteers were scanned: (1) Prone on a Civco Contoura Bellyboard (BBB), (2) Prone on a Civco MR Series Bellyboard (WBB), (3) Prone with no bellyboard and (4) Supine. All scans were performed with a T2 weighted (T2 -w) turbo spin echo (TSE) sequence. Images were scored by five assessors for: (1) ease of identifying specific organs, (2) overall image quality and (3) signal to noise ratio (SNR). Temperature changes were measured for each volunteer in each position. RESULTS: Both expert scores and SNR analysis demonstrated that images obtained in the supine position allowed for easier and clearer delineation of the organs. Image factors such as artefacts and noise, along with the overall image quality, also performed better in the supine position. The carbon fibre bellyboard did not demonstrate significant heating during scanning with the T2 -w TSE transverse sequence. CONCLUSIONS: A supine position was determined to be superior to the other positions in a majority of comparisons. The volunteers did not experience any increased temperature changes during scanning on the bellyboard in comparison to the other positions.

Functional MRI for quantitative treatment response prediction in locally advanced rectal cancer.

Despite advances in multimodality treatment strategies for locally advanced rectal cancer and improvements in locoregional control, there is still a considerable variation in response to neoadjuvant chemoradiotherapy (CRT). Accurate prediction of response to neoadjuvant CRT would enable early stratification of management according to good responders and poor responders, in order to adapt treatment to improve therapeutic outcomes in rectal cancer. Clinical studies in diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) MRI have shown promising results for the prediction of therapeutic response in rectal cancer. DWI allows for assessment of tumour cellularity. DCE-MRI enables evaluation of factors of the tumour microvascular environment and changes in perfusion in response to treatment. Studies have demonstrated that predictors of good response to CRT include lower tumour pre-CRT apparent diffusion coefficient (ADC), greater percentage increase in ADC during and post CRT, and higher pre-CRT Ktrans. However, the mean ADC and Ktrans values do not adequately reflect tumour heterogeneity. Multiparametric MRI using quantitative DWI and DCE-MRI in combination, and a histogram analysis technique can assess tumour heterogeneity and its response to treatment. This strategy has the potential to improve the accuracy of therapeutic response prediction in rectal cancer and warrants further investigation.

Substitute CT generation from a single ultra short time echo MRI sequence: preliminary study.

In MR guided radiation therapy planning both MR and CT images for a patient are acquired and co-registered to obtain a tissue specific HU map. Generation of the HU map directly from the MRI would eliminate the CT acquisition and may improve radiation therapy planning. In this preliminary study of substitute CT (sCT) generation, two porcine leg phantoms were scanned using a 3D ultrashort echo time (PETRA) sequence and co-registered to corresponding CT images to build tissue specific regression models. The model was created from one co-registered CT-PETRA pair to generate the sCT for the other PETRA image. An expectation maximization based clustering was performed on the co-registered PETRA image to identify the soft tissues, dense bone and air class membership probabilities. A tissue specific non linear regression model was built from one registered CT-PETRA pair dataset to predict the sCT of the second PETRA image in a two-fold cross validation schema. A complete substitute CT is generated in 3 min. The mean absolute HU error for air was 0.3 HU, bone was 95 HU, fat was 30 HU and for muscle it was 10 HU. The mean surface reconstruction error for the bone was 1.3 mm. The PETRA sequence enabled a low mean absolute surface distance for the bone and a low HU error for other classes. The sCT generated from a single PETRA sequence shows promise for the generation of fast sCT for MRI based radiation therapy planning.

MRI micturating urethrography for improved urethral delineation in prostate radiotherapy planning: a case study.

Stereotactic ablative body radiotherapy is used in prostate cancer to deliver a high dose of radiation to the tumour over a small number of treatments. This involves the simulation of the patient using both CT and MRI. Current practice is to insert an indwelling catheter (IDC) during CT to assist with visualisation of the urethra and subsequently minimise dose to this highly critical structure. However, this procedure is invasive and has an associated risk of infection. This is a case study, which demonstrates our initial experience of using a real-time non-invasive MRI technique to replace the use of IDC for prostate cancer patients. The patient was scanned on a dedicated 3T MRI and was instructed to micturate in their own time whereupon a sagittal T2 weighted HASTE sequence was acquired every 5 s. This was subsequently followed by T2 weighted axial imaging at the level of mid prostate to provide improved urethral definition. Acquired images showed bladder voidance in real-time and an increase in signal intensity in the proximal urethra post voiding allowing for delineation of the urethra. The dimension and shape of the proximal urethra was well visualised and accumulation time of urine in the urethra was sufficient to enable optimum timing of the scanning technique. We have presented for the first time a micturating urethography technique using MRI, which has allowed us to visualise the urethra without contrast and with minimal invasiveness to the patient.

An MRI-compatible patient rotation system - design, construction, and first organ deformation results.

PURPOSE: Conventionally in radiotherapy, a very heavy beam forming apparatus (gantry) is rotated around a patient. From a mechanical perspective, a more elegant approach is to rotate the patient within a stationary beam. Key obstacles to this approach are patient tolerance and anatomical deformation. Very little information on either aspect is available in the literature. The purpose of this work was therefore to design and test an MRI-compatible patient rotation system such that the feasibility of a patient rotation workflow could be tested. METHODS: A patient rotation system (PRS) was designed to fit inside the bore of a 3T MRI scanner (Skyra, Siemens) such that 3D images could be acquired at different rotation angles. Once constructed, a pelvic imaging study was carried out on a healthy volunteer. T2-weighted MRI images were taken every 45° between 0° and 360°, (with 0° equivalent to supine). The prostate, bladder, and rectum were segmented using atlas-based auto contouring. The images from each angle were registered back to the 0° image in three steps: (a) Rigid registration was based on MRI visible markers on the couch. (b) Rigid registration based on the prostate contour (equivalent to a rigid shift to the prostate). (c) Nonrigid registration. The Dice similarity coefficient (DSC) and mean average surface distance (MASD) were calculated for each organ at each step. RESULTS: The PRS met all design constraints and was successfully integrated with the MRI scanner. Phantom images showed minimal difference in signal or noise with or without the PRS in the MRI scanner. For the MRI images, the DSC (mean ± standard deviation) over all angles in the prostate, rectum, and bladder was 0.60 ± 0.11, 0.56 ± 0.15, and 0.76 ± 0.06 after rigid couch registration, 0.88 ± 0.03, 0.81 ± 0.08, and 0.86 ± 0.03 after rigid prostate guided registration, and 0.85 ± 0.03, 0.88 ± 0.02, 0.87 ± 0.02 after nonrigid registration. CONCLUSIONS: An MRI-compatible patient rotation system has been designed, constructed, and tested. A pelvic study was carried out on a healthy volunteer. Rigid registration based on the prostate contour yielded DSC overlap statistics in the prostate superior to interobserver contouring variability reported in the literature.

The integration of MRI in radiation therapy: collaboration of radiographers and radiation therapists.

The increased utilisation of magnetic resonance imaging (MRI) in radiation therapy (RT) has led to the implementation of MRI simulators for RT treatment planning and influenced the development of MRI-guided treatment systems. There is extensive literature on the advantages of MRI for tumour volume and organ-at-risk delineation compared to computed tomography. MRI provides both anatomical and functional information for RT treatment planning (RTP) as well as quantitative information to assess tumour response for adaptive treatment. Despite many advantages of MRI in RT, introducing an MRI simulator into a RT department is a challenge. Collaboration between radiographers and radiation therapists is paramount in making the best use of this technology. The cross-disciplinary training of radiographers and radiation therapists alike is an area rarely discussed; however, it is becoming an important requirement due to detailed imaging needs for advanced RT treatment techniques and with the emergence of hybrid treatment systems. This article will discuss the initial experiences of a radiation oncology department in implementing a dedicated MRI simulator for RTP, with a focus on the training required for both radiographer and RT staff. It will also address the future of MRI in RT and the implementation of MRI-guided treatment systems, such as MRI-Linacs, and the role of both radiation therapists and radiographers in this technology.

Quality assurance of registration of CT and MRI data sets for treatment planning of radiotherapy for head and neck cancers.

We are implementing the use of magnetic resonance (MR) images for head and neck radiotherapy planning, which involves their registration with computed tomography (CT). The quality assurance (QA) of the registration process was an initial step of this program. A phantom was built, and appropriate materials were identified to produce clinically relevant MR T1 and T2 contrast for its constituent "anatomy". We performed a characterization of the distortion detectable within our phantom. Finally, we assessed the accuracy of image registration by contouring structures in the registered/fused data sets using the treatment planning system. Each structure was contoured using each modality, in turn, blind of the other. The position, area, and perimeter of each structure were assessed as a measure of accuracy of the entire image registration process. Distortion effects in the MR image were shown to be minimized by choosing a suitable (3 +/- 30 kHz) receiver bandwidth. Remaining distortion was deemed clinically acceptable within +/-15 cm of the magnetic field isocenter. A coefficient of agreement (A) analysis gave values to be within 9% of unity, where A = square root(RaRp) and Ra/p is the ratio of the area/perimeter of a particular structure on CT to that on MR. The center of each structure of interest agreed to within 1.8 mm. A QA process has been developed to assess the accuracy of using multimodality image registration in the planning of radiotherapy for the head and neck; we believe its introduction is feasible and safe.

Magnetic resonance imaging acquisition techniques for radiotherapy planning.

Magnetic resonance imaging (MRI) has a number of benefits for the planning of radiotherapy (RT), but its uptake into clinical practice has often been restricted to specialist research sites. There is often a lack of detailed MRI knowledge within the RT community and an apprehension of geometric distortions, both of which prevent its best utilization and merit the introduction of a standardized approach and common guidelines. This review sets out to address some of the issues involved in acquiring MRI scans for RT planning in the context of a number of clinical sites of interest and concludes with recommendations for its best practice in terms of imaging protocol and quality assurance. The article is of particular interest to the growing number of cancer therapy centers that are embarking on MRI simulation on either existing systems or their own dedicated scanners.

Correlation of ADC and T2 measurements with cell density in prostate cancer at 3.0 Tesla.

OBJECTIVES: To assess the relationship between MRI derived parameters (apparent diffusion coefficient (ADC) and T2 relaxation time) and tumor cellularity as determined from whole mounted radical prostatectomy specimens, for both prostatic carcinoma and normal peripheral zone tissue. MATERIALS AND METHODS: Over a 16-month period, 20 patients (mean age: 61 years, range: 42-70 years) were prospectively recruited. Diffusion and T2 imaging were performed on a 3.0 Tesla scanner to enable subsequent ADC and T2 calculation. After radical retropubic prostatectomy specimens were whole-mounted and regions of interest (ROIs) drawn in areas of prostatic carcinoma and normal peripheral zone. Cell density was then determined using an adaptive histogram thresholding technique. Differences in tissue type were explored using the unpaired t test while the relationship between parameters was assessed using scatter-plots and the Pearson correlation coefficient. RESULTS: Significant differences (P < 0.0001 in all cases) were noted between peripheral zone tissue and prostatic carcinoma in terms of ADC (1.88 +/- 0.22 vs. 1.43 +/- 0.19 x 10(-3) mm2/s), T2 (142 +/- 24 vs. 109 +/- 20 milliseconds), and cell density (9.4% +/- 3.0% vs. 19.8% +/- 5.3%). A significant negative correlation with cell density was noted for both ADC (R = -0.695, P < 0.0001) and T2 (R = -0.505, P = 0.001). Trends for increased cell density, decreased ADC, and decreased T2 with increasing Gleason score were also noted. CONCLUSIONS: ADC and to a lesser extent T2 are good indicators of cell density. Because of the potential link with Gleason score, MRI derived parameters may have a prognostic role with regard to potential metastatic activity and tumor aggressiveness.