Robotic MR-guided high dose rate brachytherapy needle implantation in the prostate (ROBiNSon)-a proof-of-concept study.

Objective.A robotic needle implant device for MR-guided high-dose-rate (HDR) prostate brachytherapy was developed. This study aimed to assess the feasibility and spatial accuracy of HDR brachytherapy using the robotic device, for a single intraprostatic target point.Approach.Five patients were treated from November 2019-June 2022 with the robot. The robot fits a 1.5 T MR scanner and the needle can be shifted and angulated. An intraprocedural MR scan was fused with the diagnostic MR and one preplanned needle position was selected for robotic insertion. The needle entry point and angles were set for a needle tip target point within the intraprostatic target volume. The needle was tapped stepwise towards the target point pneumatically. Final needle position was verified with MR, followed by plan optimization and dose delivery. Any remaining planned needles were inserted manually. Needle tip to geometrical target error (NTG-error) was defined as the deviation of the actual tip position relative to the predefined geometric target point, using MR-coordinates. Needle tip to treatment target error (NTT-error) was defined as the deviation of the actual tip position relative to the treatment target point, using fused MR-images pre- and post-needle implantation taking into account prostate deformation. Difference between NTT-error and NTG-error and fiducial marker shifts indicated prostate movement. For determining prostate deformation, the Jaccard index and prostate volumes were assessed.Main results.The robotic device was able to tap the needle to the planned depth for all patients. Mean robotic procedure duration was 142 min. NTG-error was 3.2 (range 1.1-6.7) mm and NTT-error 4.5 (range 2.6-9.6) mm. Marker displacements were smaller than 3 mm. No treatment-related acute toxicity was reported. Feasibility of needle placement within the prostate was considered adequate.Significance.MR-guided robotic needle insertion is feasible with a mean geometric accuracy of 3.2 mm and <3 mm prostate movement.

Intrafraction motion analysis in online adaptive radiotherapy for esophageal cancer.

Intrafraction motion during magnetic resonance (MR)-guided dose delivery of esophageal cancer tumors was retrospectively analyzed. Deformable image registration of cine-MR series resulted in gross tumor volume motion profiles in all directions, which were subsequently filtered to isolate respiratory and drift motion. A large variability in intrafraction motion patterns was observed between patients. Median 95% peak-to-peak motion was 7.7 (3.7 - 18.3) mm, 2.1 (0.7 - 5.7) mm and 2.4 (0.5 - 5.6) mm in cranio-caudal, left-right and anterior-posterior directions, relatively. Furthermore, intrafraction drift was generally modest (<5mm). A patient specific approach could lead to very small margins (<3mm) for most patients.

Clinical application of a sub-fractionation workflow for intrafraction re-planning during prostate radiotherapy treatment on a 1.5 Tesla MR-Linac: A practical method to mitigate intrafraction motion.

BACKGROUND: Intrafraction motion during radiotherapy limits margin reduction and dose escalation. Magnetic resonance (MR)-guided linear accelerators (MR-Linac) have emphasised this issue by enabling intrafraction imaging. We present and clinically apply a new workflow to counteract systematic intrafraction motion during MR-guided stereotactic body radiotherapy (SBRT). MATERIALS AND METHODS: With the sub-fractionation workflow, the daily dose is delivered in multiple sequential parts (sub-fractions), each adapted to the latest anatomy. As each sub-fractionation treatment plan complies with the dose constraints, no online dose accumulation is required. Imaging and treatment planning are executed in parallel with dose delivery to minimise dead time, enabling an efficient workflow. The workflow was implemented on a 1.5 T MR-Linac and applied in 15 prostate cancer (PCa) patients treated with 5 × 7.25 Gy in two sub-fractions of 3.625 Gy (10 × 3.625 Gy in total). Intrafraction clinical target volume (CTV) motion was determined and compared to a workflow with single-plan delivery. Furthermore, required planning target volume (PTV) margins were determined. RESULTS: Average on-table time was 42.7 min. Except for two fractions, all fractions were delivered within 60 min. Average intrafraction 3D CTV displacement (±standard deviation) was 1.1 mm (± 0.7) with the sub-fractionation workflow, whereas this was up to 3.5 mm (± 2.4) without sub-fractionation. Calculated PTV margins required with sub-fractionation were 1.0 mm (left-right), 2.4 mm (cranial-caudal), and 2.6 mm (anterior-posterior). CONCLUSION: Feasibility of the sub-fractionation workflow was demonstrated in 15 PCa patients treated with two sub-fractions on a 1.5 T MR-Linac. The workflow allows for significant PTV margin reduction in these patients by reducing systematic intrafraction motion during SBRT.

A mask-compatible, radiolucent, 8-channel head and neck receive array for MRI-guided radiotherapy treatments and pre-treatment simulation.

Immobilization masks are used to prevent patient movement during head and neck (H&N) radiotherapy. Motion restriction is beneficial both during treatment, as well as in the pre-treatment simulation phase, where magnetic resonance imaging (MRI) is often used for target definition. However, the shape and size of the immobilization masks hinder the use of regular, close-fitting MRI receive arrays. In this work, we developed a mask-compatible 8-channel H&N array that consists of a single-channel baseplate, on which the mask can be secured, and a flexible 7-channel anterior element that follows the shape of the mask. The latter uses high impedance coils to achieve its flexibility and radiolucency. A fully-functional prototype was manufactured, its radiolucency was characterized, and the gain in imaging performance with respect to current clinical setups was quantified. Dosimetry measurements showed an overall dose change of -0.3%. Small, local deviations were up to -2.7% but had no clinically significant impact on a full treatment plan, as gamma pass rates (3%/3 mm) only slightly reduced from 97.9% to 97.6% (clinical acceptance criterion: ≥95%). The proposed H&N array improved the imaging performance with respect to three clinical setups. The H&N array more than doubled (+123%) and tripled (+246%) the signal-to-noise ratio with respect to the clinical MRI-simulation and MR-linac setups, respectively.G-factors were also lower with the proposed H&N array. The improved imaging performance resulted in a clearly visible signal-to-noise ratio improvement of clinically used TSE and DWI acquisitions. In conclusion, the 8-channel H&N array improves the imaging performance of MRI-simulation and MR-linac acquisitions, while dosimetry suggests that no clinically significant dose changes are induced.

Accumulated bladder wall dose is correlated with patient-reported acute urinary toxicity in prostate cancer patients treated with stereotactic, daily adaptive MR-guided radiotherapy.

BACKGROUND AND PURPOSE: Magnetic resonance (MR)-guided linear accelerators (MR-Linac) enable accurate estimation of delivered doses through dose accumulation using daily MR images and treatment plans. We aimed to assess the association between the accumulated bladder (wall) dose and patient-reported acute urinary toxicity in prostate cancer (PCa) patients treated with stereotactic body radiation therapy (SBRT). MATERIALS AND METHODS: One-hundred-and-thirty PCa patients treated on a 1.5 T MR-Linac were included. Patients filled out International Prostate Symptom Scores (IPSS) questionnaires at baseline, 1 month, and 3 months post-treatment. Deformable image registration-based dose accumulation was performed to reconstruct the delivered dose. Dose parameters for both bladder and bladder wall were correlated with a clinically relevant increase in IPSS (≥ 10 points) and/or start of alpha-blockers within 3 months using logistic regression. RESULTS: Thirty-nine patients (30%) experienced a clinically relevant IPSS increase and/or started with alpha-blockers. Bladder D5cm3, V10-35Gy (in %), and Dmean and Bladder wall V10-35Gy (cm3 and %) and Dmean were correlated with the outcome (odds ratios 1.04-1.33, p-values 0.001-0.044). Corrected for baseline characteristics, bladder V10-35Gy (in %) and Dmean and bladder wall V10-35Gy (cm3 and %) and Dmean were still correlated with the outcome (odds ratios 1.04-1.30, p-values 0.001-0.028). Bladder wall parameters generally showed larger AUC values. CONCLUSION: This is the first study to assess the correlation between accumulated bladder wall dose and patient-reported urinary toxicity in PCa patients treated with MR-guided SBRT. The dose to the bladder wall is a promising parameter for prediction of patient-reported urinary toxicity and therefore warrants prospective validation and consideration in treatment planning.

Dynamic Contrast-enhanced and Diffusion-weighted Magnetic Resonance Imaging for Response Evaluation After Single-Dose Ablative Neoadjuvant Partial Breast Irradiation.

Purpose: We aimed to evaluate changes in dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) magnetic resonance imaging (MRI) scans acquired before and after single-dose ablative neoadjuvant partial breast irradiation (NA-PBI), and explore the relation between semiquantitative MRI parameters and radiologic and pathologic responses. Methods and Materials: We analyzed 3.0T DCE and DW-MRI of 36 patients with low-risk breast cancer who were treated with single-dose NA-PBI, followed by breast-conserving surgery 6 or 8 months later. MRI was acquired before NA-PBI and 1 week, 2, 4, and 6 months after NA-PBI. Breast radiologists assessed the radiologic response and breast pathologists scored the pathologic response after surgery. Patients were grouped as either pathologic responders or nonresponders (<10% vs ≥10% residual tumor cells). The semiquantitative MRI parameters evaluated were time to enhancement (TTE), 1-minute relative enhancement (RE1min), percentage of enhancing voxels (%EV), distribution of washout curve types, and apparent diffusion coefficient (ADC). Results: In general, the enhancement increased 1 week after NA-PBI (baseline vs 1 week median - TTE: 15s vs 10s; RE1min: 161% vs 197%; %EV: 47% vs 67%) and decreased from 2 months onward (6 months median - TTE: 25s; RE1min: 86%; %EV: 12%). Median ADC increased from 0.83 × 10-3 mm2/s at baseline to 1.28 × 10-3 mm2/s at 6 months. TTE, RE1min, and %EV showed the most potential to differentiate between radiologic responses, and TTE, RE1min, and ADC between pathologic responses. Conclusions: Semiquantitative analyses of DCE and DW-MRI showed changes in relative enhancement and ADC 1 week after NA-PBI, indicating acute inflammation, followed by changes indicating tumor regression from 2 to 6 months after radiation therapy. A relation between the MRI parameters and radiologic and pathologic responses could not be proven in this exploratory study.

Fast and accurate deformable contour propagation for intra-fraction adaptive magnetic resonance-guided prostate radiotherapy.

To facilitate full intra-fraction adaptive MR-guided radiotherapy, accurate contour propagation is needed. We aimed to assess the clinical usability of intra-fraction propagated contours by a deformable image registration algorithm in ten prostate cancer patients. Two observers judged the contours on need for manual adaptation and feasibility of adapting contours within 3 min. CTV and bladder contours needed none or only minor editing in most cases (≥ 97%), whereas rectum contours needed more extensive editing in 12-23%. Nevertheless, adaptation times were < 3 min for ≥ 93% of the cases. This paves the way for exploring adaptive workflows using intra-fraction deformable contour propagation.

Minimizing the need for coil attenuation correction in integrated PET/MRI at 1.5 T using low-density MR-linac receive arrays.

The simultaneous use of positron emission tomography (PET) and magnetic resonance imaging (MRI) requires attenuation correction (AC) of photon-attenuating objects, such as MRI receive arrays. However, AC of flexible, on-body arrays is complex and therefore often omitted. This can lead to significant, spatially varying PET signal losses when conventional MRI receive arrays are used. Only few dedicated, photon transparent PET/MRI arrays exist, none of which are compatible with our new, wide-bore 1.5 T PET/MRI system dedicated to radiotherapy planning. In this work, we investigated the use of 1.5 T MR-linac (MRL) receive arrays for PET/MRI, as these were designed to have a low photon attenuation for accurate dose delivery and can be connected to the new 1.5 T PET/MRI scanner. Three arrays were assessed: an 8-channel clinically-used MRL array, a 32-channel prototype MRL array, and a conventional MRI receive array. We experimentally determined, simulated, and compared the impact of these arrays on the PET sensitivity and image reconstructions. Furthermore, MRI performance was compared. Overall coil-induced PET sensitivity losses were reduced from 8.5% (conventional) to 1.7% (clinical MRL) and 0.7% (prototype MRL). Phantom measurements showed local signal errors of up to 32.7% (conventional) versus 3.6% (clinical MRL) and 3.5% (prototype MRL). Simulations with data of eight cancer patients showed average signal losses were reduced from 14.3% (conventional) to 1.2% (clinical MRL) and 1.0% (prototype MRL). MRI data showed that the signal-to-noise ratio of the MRL arrays was slightly lower at depth (110 versus 135). The parallel imaging performance of the conventional and prototype MRL arrays was similar, while the clinical MRL array's performance was lower. In conclusion, MRL arrays reducein-vivoPET signal losses >10×, which decreases, or eliminates, the need for coil AC on a new 1.5 T PET/MRI system. The prototype MRL array allows flexible coil positioning without compromising PET or MRI performance. One limitation of MRL arrays is their limited radiolucent PET window (field of view) in the craniocaudal direction.

Real-time 3D motion estimation from undersampled MRI using multi-resolution neural networks.

PURPOSE: To enable real-time adaptive magnetic resonance imaging-guided radiotherapy (MRIgRT) by obtaining time-resolved three-dimensional (3D) deformation vector fields (DVFs) with high spatiotemporal resolution and low latency ( < 500  ms). Theory and Methods: Respiratory-resolved T 1 -weighted 4D-MRI of 27 patients with lung cancer were acquired using a golden-angle radial stack-of-stars readout. A multiresolution convolutional neural network (CNN) called TEMPEST was trained on up to 32 × retrospectively undersampled MRI of 17 patients, reconstructed with a nonuniform fast Fourier transform, to learn optical flow DVFs. TEMPEST was validated using 4D respiratory-resolved MRI, a digital phantom, and a physical motion phantom. The time-resolved motion estimation was evaluated in-vivo using two volunteer scans, acquired on a hybrid MR-scanner with integrated linear accelerator. Finally, we evaluated the model robustness on a publicly-available four-dimensional computed tomography (4D-CT) dataset. RESULTS: TEMPEST produced accurate DVFs on respiratory-resolved MRI at 20-fold acceleration, with the average end-point-error < 2  mm, both on respiratory-sorted MRI and on a digital phantom. TEMPEST estimated accurate time-resolved DVFs on MRI of a motion phantom, with an error < 2  mm at 28 × undersampling. On two volunteer scans, TEMPEST accurately estimated motion compared to the self-navigation signal using 50 spokes per dynamic (366 × undersampling). At this undersampling factor, DVFs were estimated within 200 ms, including MRI acquisition. On fully sampled CT data, we achieved a target registration error of 1.87 ± 1.65 mm without retraining the model. CONCLUSION: A CNN trained on undersampled MRI produced accurate 3D DVFs with high spatiotemporal resolution for MRIgRT.

On-line daily plan optimization combined with a virtual couch shift procedure to address intrafraction motion in prostate magnetic resonance guided radiotherapy.

BACKGROUND AND PURPOSE: In daily adaptive magnetic resonance (MR)-guided radiotherapy, plans are adapted based on the patient's daily anatomy. During this adaptation phase, prostate intrafraction motion (IM) can occur. The aim of this study was to investigate the efficacy of always applying a subsequent virtual couch shift (VCS) to counter IM that occurred during the daily contour and plan adaption (CPa) procedure. MATERIAL AND METHODS: One hundred fifty patients with low and intermediate risk prostate cancer were treated with 5x7.25 Gy fractions on a 1.5 T MR-Linac. In each fraction, contour adaptation and dose re-optimization was performed using the session's first MR-scan. IM that occurred here was countered using two methods. One patient group had selective VCS (sVCS) applied if the CTV reached outside the PTV on a second MR acquired during plan optimization. The other group had always VCS (aVCS) applied for any prostate shift greater than 1 mm. Remaining IM during beam delivery was determined using 3D cine-MR. RESULTS: Percentage of fractions where a VCS was applied was 28% (sVCS) vs 78% (aVCS). Always applying VCS significantly reduced influences of systematic prostate IM. Population random and systematic median values in all translations directions were lower for the aVCS than sVCS group, but not for the population random cranial-caudal direction. CONCLUSION: Applying VCS after daily CPa reduced impact of systematic prostate drift in especially the posterior and caudal translation direction. However, due to the continuous and stochastical nature of prostate IM, margin reduction below 4 mm requires fast intrafraction plan adaption methods.

Development and internal validation of multivariable prediction models for biochemical failure after MRI-guided focal salvage high-dose-rate brachytherapy for radiorecurrent prostate cancer.

BACKGROUND AND PURPOSE: Magnetic resonance-guided focal salvage high-dose-rate brachytherapy (FS-HDR-BT) for radiorecurrent prostate cancer (PCa) shows low toxicity rates. However, biochemical failure (BF) after treatment occurs frequently. We developed two prediction models for BF (Phoenix definition) with the aim of enhancing patient counselling before FS-HDR-BT and during follow-up. MATERIALS AND METHODS: A prospective cohort of 150 radiorecurrent PCa patients treated with FS-HDR-BT between 2013 and 2020 was used for model development and internal validation. Multivariable Cox Proportional Hazards regression was applied. For model 1, only pre-salvage variables were included as candidate predictors. For model 2, additional (post-)salvage characteristics were tested. After calibration, nomograms and webtools were constructed. Finally, three risk groups were identified. RESULTS: Sixty-one patients (41%) experienced BF. At baseline (model 1), age, gross tumour volume, pre-salvage PSA, and pre-salvage PSA doubling time (PSADT) were predictive of BF. During follow-up (model 2), age, pre-salvage PSA and PSADT, seminal vesicle involvement, post-salvage time to PSA nadir, and percentage PSA reduction were predictive of BF. The adjusted C-statistics were 0.73 (95% CI: 0.66-0.81) and 0.84 (95% CI: 0.78-0.90), respectively, with acceptable calibration. Estimated 2-year biochemical disease-free survival for the low-, intermediate-, and high-risk groups were 84%, 70%, and 31% (model 1), and 100%, 71%, and 5% (model 2). CONCLUSION: Two models are provided for prediction of BF in patients with radiorecurrent PCa treated with FS-HDR-BT. Based on pre- and post-salvage characteristics, we are able to identify patients with a high risk of BF. These findings can aid patient counselling for FS-HDR-BT.

Acceptance procedure for the linear accelerator component of the 1.5 T MRI-linac.

PURPOSE: To develop and implement an acceptance procedure for the new Elekta Unity 1.5 T MRI-linac. METHODS: Tests were adopted and, where necessary adapted, from AAPM TG106 and TG142, IEC 60976 and NCS 9 and NCS 22 guidelines. Adaptations were necessary because of the atypical maximum field size (57.4 × 22 cm), FFF beam, the non-rotating collimator, the absence of a light field, the presence of the 1.5 T magnetic field, restricted access to equipment within the bore, fixed vertical and lateral table position, and the need for MR image to MV treatment alignment. The performance specifications were set for stereotactic body radiotherapy (SBRT). RESULTS: The new procedure was performed similarly to that of a conventional kilovoltage x-ray (kV) image guided radiation therapy (IGRT) linac. Results were acquired for the first Unity system. CONCLUSIONS: A comprehensive set of tests was developed, described and implemented for the MRI-linac. The MRI-linac met safety requirements for patients and operators. The system delivered radiation very accurately with, for example a gantry rotation locus of isocenter of radius 0.38 mm and an average MLC absolute positional error of 0.29 mm, consistent with use for SBRT. Specifications for clinical introduction were met.

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 < 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 < 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 < 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.

Evaluation of daily online contour adaptation by radiation therapists for prostate cancer treatment on an MRI-guided linear accelerator.

BACKGROUND AND PURPOSE: Magnetic resonance (MR)-guided linear accelerator (MR-Linac) systems have changed radiotherapy workflows. The addition of daily online contour adaptation allows for higher precision treatment, but also increases the workload of those involved. We train radiation therapists (RTTs) to perform daily online contour adaptation for MR-Linac treatment of prostate cancer (PCa) patients. The purpose of this study was to evaluate these prostate contours by performing an interfraction and interobserver analysis. MATERIALS AND METHODS: Clinical target volume (CTV) contours generated online by RTTs from 30 low-intermediate risk PCa patients, treated with 5x7.25 Gy, were used. Two physicians (Observers) judged the RTTs contours and performed adaptations when necessary. Interfraction relative volume differences between the first and the subsequent fractions were calculated for the RTTs, Observer 1, and Observer 2. Additionally, interobserver dice's similarity coefficient (DSC) for fraction 2-5 was calculated with the RTTs- and physician-adapted contours. Clinical acceptability of the RTTs contours was judged by a third observer. RESULTS: Mean (SD) online contour adaptation time was 12.6 (±3.8) minutes and overall median (interquartile range [IQR]) relative volume difference was 9.3% (4.4-13.0). Adaptations by the observers were mostly performed at the apex and base of the prostate. Median (IQR) interobserver DSC between RTTs and Observer 1, RTTs and Observer 2, and Observer 1 and 2 was 0.99 (0.98-1.00), 1.00 (0.98-1.00), and 1.00 (0.99-1.00), respectively. Contours were acceptable for clinical use in 113 (94.2%) fractions. Dose-volume histogram (DVH) analysis showed significant CTV underdosage for one of the seven identified outliers. CONCLUSION: Daily online contour adaptation by RTTs is clinically feasible for MR-Linac treatment of PCa.

Problems and Promises of Introducing the Magnetic Resonance Imaging Linear Accelerator Into Routine Care: The Case of Prostate Cancer.

The new radiotherapy high field, 1.5 Tesla MRI-guided linear accelerator (MR-Linac) is being clinically introduced. Sensing and evaluating opportunities and barriers at an early stage will facilitate its eventual scale-up. This study investigates the opportunities and barriers to the implementation of MR-Linac into prostate cancer care based on 43 semi-structured interviews with Dutch oncology care professionals, hospital and division directors, patients, payers and industry. The analysis was guided by the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability framework of new medical technologies and services. Opportunities included: the acquirement of (1) advanced MRI-guided radiotherapy technology with (2) the potential for improved patient outcomes and (3) economic benefits, as well as (4) professional development and (5) a higher hospital quality profile. Barriers included: (1) technical complexities, (2) substantial staffing and structural investments, (3) the current lack of empirical evidence of clinical benefits, (4) professional silos, and (5) the presence of patient referral patterns. While our study confirms the expected technical and clinical prospects from the literature, it also reveals economic, organizational, and socio-political challenges.

Optimizing MR-Guided Radiotherapy for Breast Cancer Patients.

Current research in radiotherapy (RT) for breast cancer is evaluating neoadjuvant as opposed to adjuvant partial breast irradiation (PBI) with the aim of reducing the volume of breast tissue irradiated and therefore the risk of late treatment-related toxicity. The development of magnetic resonance (MR)-guided RT, including dedicated MR-guided RT systems [hybrid machines combining an MR scanner with a linear accelerator (MR-linac) or 60Co sources], could potentially reduce the irradiated volume even further by improving tumour visibility before and during each RT treatment. In this position paper, we discuss MR guidance in relation to each step of the breast RT planning and treatment pathway, focusing on the application of MR-guided RT to neoadjuvant PBI.

Advanced patient-specific hyperthermia treatment planning.

Hyperthermia treatment planning (HTP) is valuable to optimize tumor heating during thermal therapy delivery. Yet, clinical hyperthermia treatment plans lack quantitative accuracy due to uncertainties in tissue properties and modeling, and report tumor absorbed power and temperature distributions which cannot be linked directly to treatment outcome. Over the last decade, considerable progress has been made to address these inaccuracies and therefore improve the reliability of hyperthermia treatment planning. Patient-specific electrical tissue conductivity derived from MR measurements has been introduced to accurately model the power deposition in the patient. Thermodynamic fluid modeling has been developed to account for the convective heat transport in fluids such as urine in the bladder. Moreover, discrete vasculature trees have been included in thermal models to account for the impact of thermally significant large blood vessels. Computationally efficient optimization strategies based on SAR and temperature distributions have been established to calculate the phase-amplitude settings that provide the best tumor thermal dose while avoiding hot spots in normal tissue. Finally, biological modeling has been developed to quantify the hyperthermic radiosensitization effect in terms of equivalent radiation dose of the combined radiotherapy and hyperthermia treatment. In this paper, we review the present status of these developments and illustrate the most relevant advanced elements within a single treatment planning example of a cervical cancer patient. The resulting advanced HTP workflow paves the way for a clinically feasible and more reliable patient-specific hyperthermia treatment planning.

Improving the imaging performance of the 1.5 T MR-linac using a flexible, 32-channel, on-body receive array.

High impedance coils (HICs) are suitable as a building block of receive arrays for MRI-guided radiotherapy (MRIgRT) as HICs do not require radiation-attenuating capacitors and dense support materials. Recently, we proved the feasibility of using HICs to create a radiation transparent (i.e. radiolucent) window. In this work, we constructed a fully functional 32-channel array based on this design. The anterior element is flexible and follows the shape of the subject, while the posterior element is rigid to support the subject. Both elements feature a 2 × 8 channel layout. Here, we discuss the construction process and characterize the array's radiolucency and imaging performance. The dosimetric impact of the array was quantified by assessing the surface dose increase and attenuation of a single beam. The imaging performance of the prototype was compared to the clinical array in terms of visual appearance, signal-to-noise ratio (SNR), and acceleration performance, both in phantom and in-vivo measurements. Dosimetry measurements showed that on-body placement changed the anterior and posterior surface dose by +3% and -16% of the dose maximum. Attenuation under the anterior support materials and conductors was 0.3% and ≤1.5%, respectively. Phantom and in-vivo imaging with this array demonstrated an improvement of the SNR at the surface and the image quality in general. Simultaneous irradiation did not affect the SNR. G-factors were reduced considerably and clinically used sequences could be accelerated by up to 45%, which would greatly reduce pre-beam imaging times. Finally, the maximally achievable temporal resolution of abdominal 3D cine imaging was improved to 1.1 s, which was > 5 × faster than could be achieved with the clinical array. This constitutes a big step towards the ability to resolve respiratory motion in 3D. In conclusion, the proposed 32-channel array is compatible with MRIgRT and can significantly reduce scan times and/or improve the image quality of all on-line scans.

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.