Towards real-time 4D radiation dosimetry on an MRI-Linac

4D radiation dosimetry using a highly radiation-sensitive polymer gel dosimeter with real-time quantitative magnetic resonance imaging (MRI) readout is presented as a technique to acquire the accumulated radiation dose distribution during image-guided radiotherapy on an MRI-Linac. Optimized T ₂-weighted Turbo-Spin-Echo (TSE) scans are converted into quantitative ΔR ₂ maps and subsequently to radiation dose maps. The concept of temporal uncertainty is introduced as a metric of effective temporal resolution. A mathematical framework is presented to optimize the echo time of the TSE sequence in terms of dose resolution, and the trade-off between temporal resolution and dose resolution is discussed. The current temporal uncertainty achieved with the MAGAT gel dosimeter on a 1 T MRI-Linac is 3.8 s which is an order of magnitude better than what has been achieved until now. The potential of real-time 4D radiation dosimetry in a theragnostic MRI-Linac is demonstrated for two scenarios: an irradiation with three coplanar beams on a head phantom and a dynamic arc treatment on a cylindrical gel phantom using a rotating couch. The dose maps acquired on the MRI-Linac are compared with a treatment plan and with dose maps acquired on a clinical 3 T MRI scanner. 3D gamma map evaluations for the different modalities are provided. While the presented method demonstrates the potential of gel dosimetry for tracking the dose delivery during radiotherapy in 4D, a shortcoming of the MAGAT gel dosimeter is a retarded dose response. The effect of non-ideal radiofrequency pulses resulting from limitations in the specific absorption rate or B₁-field inhomogeneity on the TSE acquired ΔR ₂ values is analysed experimentally and by use of computational modelling with a Bloch simulator.

Regional cardiac dysfunction determined by radiation dose in patients with breast cancer

Background

Subclinical left ventricular (LV) dysfunction by 2D global longitudinal strain (GLS) immediately following radiotherapy (RT) and persisting at 12 months has been described in breast cancer (BC) patients. We hypothesised that persistent LV dysfunction may be regional and correlate with segmental RT.

Methods

Transthoracic echocardiograms were performed at baseline, 6 weeks and 12 months post-RT on 61 chemotherapy-naïve women with left sided BC.

Results

Anterior and anteroseptal regions received the highest radiation dose, and posterior and inferior segments the lowest radiation dose (Figure 1). Within each region, there was a progressive increase in the radiation dose received from base to apex. At 6 weeks, the greatest reduction in strain was observed in the anterior and anteroseptal regions, with the most significant reduction in strain in the apical segments. At 12 months, despite improvement in strain, the percentage reduction in strain was similar. There was a significant interaction between both region and segment, on the percentage change in strain at 6 weeks (p<0.001) and at 12 months (p=0.007). Pairwise comparisons of apical to basal percentage change in strain demonstrated the most significant reductions in the anterior region at 6 weeks and 12 months (Table 1).

Conclusions

RT causes segmental myocardial dysfunction, with areas receiving the highest RT demonstrating the largest impairment in strain, with these changes persisting at 12 months. Long term correlation with adverse events is required.

Figure 1. Radiation dose by region and segment

Funding Acknowledgement

Type of funding source: None

Enhanced MRI-guided radiotherapy with gadolinium-based nanoparticles: preclinical evaluation with an MRI-linac

Background

The AGuIX® (NH TherAguix) nanoparticle has been developed to enhance radiotherapy treatment and provide strong MR contrast. These two properties have previously been investigated separately and progressed to clinical trial following a clinical workflow of separate MR imaging followed some time later by radiotherapy treatment. The recent development of MRI-linacs (combined Magnetic Resonance Imaging–linear accelerator systems enabling MRI-guided radiotherapy) opens up a new workflow where MR confirmation of nanoparticle uptake can be carried out at the time of treatment. A preclinical study was carried out to assess the suitability of a gadolinium-containing nanoparticle AGuIX® (NH TherAguix) for nano-enhanced image-guided radiotherapy on an MRI-linac.

Methods

Treatments were carried out on F344 Fischer rats bearing a 9L glioma brain tumour. Animals received either: (A) no treatment; (B) injection of nanoparticles followed by MRI; (C) radiotherapy with MRI; or (D) injection of nanoparticles followed by radiotherapy with MRI. Pre-clinical irradiations were carried out on the 1.0 T, 6 MV in-line Australian MRI-linac. Imaging used a custom head coil specially designed to minimise interference from the radiotherapy beam. Anaesthetised rats were not restrained during treatment but were monitored with a cine-MRI sequence. Inductively Coupled Plasma Mass Spectrometry (ICP-MS) analysis was used to quantify residual gadolinium in the brain in normal and tumour tissue.

Results

A preclinical evaluation of nano-enhanced radiation treatment has been carried out on a 1.0 T MRI-linac, establishing a workflow on these novel systems. Extension of life when combining radiotherapy with nanoparticles was not statistically different from that for rats receiving radiotherapy only. However, there was no detrimental effect for animals receiving nanoparticles and radiation treatment in the magnetic field compared with control branches. Cine-MR imaging was sufficient to carry out monitoring of anaesthetised animals during treatment. AGuIX nanoparticles demonstrated good positive contrast on the MRI-linac system allowing confirmation of tumour extent and nanoparticle uptake at the time of treatment.

Conclusions

Novel nano-enhanced radiotherapy with gadolinium-containing nanoparticles is ideally suited for implementation on an MRI-linac, allowing a workflow with time-of-treatment imaging. Live irradiations using this treatment workflow, carried out for the first time at the Australian MRI-linac, confirm the safety and feasibility of performing MRI-guided radiotherapy with AGuIX® nanoparticles. Follow-up studies are needed to demonstrate on an MRI-linac the radiation enhancement effects previously shown with conventional radiotherapy.

Radiotherapy beyond cancer: target localization in real-time MRI and treatment planning for cardiac radiosurgery

PURPOSE

Atrial fibrillation (AFib) is the most common cardiac arrhythmia that affects millions of patients world-wide. AFib is usually treated with minimally invasive, time consuming catheter ablation techniques. While recently noninvasive radiosurgery to the pulmonary vein antrum (PVA) in the left atrium has been proposed for AFib treatment, precise target location during treatment is challenging due to complex respiratory and cardiac motion. A MRI linear accelerator (MRI-Linac) could solve the problems of motion tracking and compensation using real-time image guidance. In this study, the authors quantified target motion ranges on cardiac magnetic resonance imaging (MRI) and analyzed the dosimetric benefits of margin reduction assuming real-time motion compensation was applied.

METHODS

For the imaging study, six human subjects underwent real-time cardiac MRI under free breathing. The target motion was analyzed retrospectively using a template matching algorithm. The planning study was conducted on a CT of an AFib patient with a centrally located esophagus undergoing catheter ablation, representing an ideal case for cardiac radiosurgery. The target definition was similar to the ablation lesions at the PVA created during catheter treatment. Safety margins of 0 mm (perfect tracking) to 8 mm (untracked respiratory motion) were added to the target, defining the planning target volume (PTV). For each margin, a 30 Gy single fraction IMRT plan was generated. Additionally, the influence of 1 and 3 T magnetic fields on the treatment beam delivery was simulated using Monte Carlo calculations to determine the dosimetric impact of MRI guidance for two different Linac positions.

RESULTS

Real-time cardiac MRI showed mean respiratory target motion of 10.2 mm (superior-inferior), 2.4 mm (anterior-posterior), and 2 mm (left-right). The planning study showed that increasing safety margins to encompass untracked respiratory motion leads to overlapping structures even in the ideal scenario, compromising either normal tissue dose constraints or PTV coverage. The magnetic field caused a slight increase in the PTV dose with the in-line MRI-Linac configuration.

CONCLUSIONS

The authors' results indicate that real-time tracking and motion compensation are mandatory for cardiac radiosurgery and MRI-guidance is feasible, opening the possibility of treating cardiac arrhythmia patients completely noninvasively.

The UK national study of magnetic resonance imaging as a method of screening for breast cancer (MARIBS)

The UK national study of magnetic resonance imaging as a method of screening for breast cancer (MARIBS) is in progress. The study design, accrual to date, and related research projects are described. Revised accrual rates and expected recruitment are given. 15 cancers have been detected to date, from a total of 1236 screening measurements. This event rate and the tumour grades reported are compared with recent reports from other studies in women at high risk of breast cancer.