No abstract

MR image-guided radiotherapy has the potential to improve patient care, but integration of an MRI scanner with a linear accelerator adds complexity to the commissioning process. This work describes a single institution experience of commissioning an Elekta Unity MR-linac, including mechanical testing, MRI scanner commissioning, and dosimetric validation. Mechanical testing included multileaf collimator (MLC) positional accuracy, measurement of radiation isocenter diameter, and MR-to-MV coincidence. Key MRI tests included magnetic field homogeneity, geometric accuracy, image quality, and the accuracy of navigator-triggered imaging for motion management. Dosimetric validation consisted of comparison between measured and calculated PDDs and profiles, IMRT measurements, and end-to-end testing. Multileaf collimator positional accuracy was within 1.0 mm, the measured radiation isocenter walkout was 0.20 mm, and the coincidence between MR and MV isocenter was 1.06 mm, which is accounted for in the treatment planning system (TPS). For a 350mm-diameter spherical volume, the peak-to-peak deviation of the magnetic field homogeneity was 4.44 ppm and the geometric distortion was 0.8 mm. All image quality metrics were within ACR recommendations. Navigator-triggered images showed a maximum deviation of 0.42, 0.75, and 3.0 mm in the target centroid location compared to the stationary target for a 20 mm motion at 10, 15, and 20 breaths per minute, respectively. TPS-calculated PDDs and profiles showed excellent agreement with measurement. The gamma passing rate for IMRT plans was 98.4 ± 1.1% (3%/ 2 mm) and end-to-end testing of adapted plans showed agreement within 0.4% between ion-chamber measurement and TPS calculation. All credentialing criteria were satisfied in an independent end-to-end test using an IROC MRgRT phantom.

Recent availability of MRI-guided linear accelerators has introduced a number of clinical challenges, particularly in the context of online plan adaptation. Paramount among these is verification of plan quality prior to patient treatment. Currently, there are no commercial products available for monitor unit verification that fully support the newly FDA cleared Elekta Unity 1.5 T MRI-linac. In this work, we investigate the accuracy and precision of RadCalc for this purpose, which is a software package that uses a Clarkson integration algorithm for point dose calculation. To this end, 18 IMRT patient plans (186 individual beams) were created and used for Rad-Calc point dose calculations. In comparison with the primary treatment planning system (Monaco), mean point dose deviations of 0.0 ± 1.0% (n = 18) and 1.7 ± 12.4% (n = 186) were obtained on a per-plan and per-beam basis, respectively. The dose plane comparison functionality within RadCalc was found to be highly inaccurate, however, modest improvements could be made by artificially shifting jaws and multi leaf collimator positions to account for the dosimetric shift due to the magnetic field (67.3% vs 96.5% mean 5%/5 mm gamma pass rate). K E Y W O R D S dose calculation, Elekta Unity, MRI-Linac, RadCalc The first 1.5 T MRI-equipped linear accelerator (Elekta Unity, Elekta AB, Stockholm, Sweden) was cleared by the U.S. Food and Drug Administration in December of 2018. Coupling a high-magnetic field MRI with a linear accelerator introduces a number of commissioning and routine quality assurance challenges that are not associated with conventional linear accelerators. Notably, all equipment ---

A full 3D design for an in-line side-coupled 6 MV linear accelerator that emulates a common commercial waveguide has been given. The effect of the side coupling on the dose distribution has been shown to create a slight asymmetry, but overall does not affect the clinical applicability of the linac. The 3D in-line side-coupled linac model further provides a tool for the investigation of linac performance within an external magnetic field, which exists in an integrated linac-MR system.

An integrated simulation of an inline side-coupled 6 MV linac has been completed and benchmarked matching all electrical and dosimetric measurements to high accuracy. The results showed non-Gaussian spatial intensity and energy distributions for the linac modeled.

In an effort to achieve higher quality images and a reduction in hot and cold spots in the treatment plan, a parallel configuration linac-MR system is presented. The longitudinal magnetic fields of the MR imager caused large beam losses within the electron gun. These losses may be eliminated through a redesign of the electron gun optics incorporating a longitudinal magnetic field, or through magnetic shielding, which has already been proven successful for the transverse configuration.

The magnetic fields of linac-MR systems modify the path of contaminant electrons in photon beams, which alters patient entrance skin dose. Also, the increased SSD of linac-MR systems reduces the maximum achievable dose rate. To accurately quantify the changes in entrance skin dose, the authors use EGSnrc Monte Carlo calculations that incorporate 3D magnetic field of the Alberta 0.5 T longitudinal linac-MR system. The Varian 600C linac head geometry assembled on the MRI components is used in the BEAMnrc simulations for 6 MV and 10 MV beam models and skin doses are calculated at an average depth of 70 μm using DOSXYZnrc. 3D modeling shows that magnetic fringe fields decay rapidly and are small at the linac head. SSDs between 100 and 120 cm result in skin-dose increases of between ~6%-19% and ~1%-9% for the 6 and 10 MV beams, respectively. For 6 MV, skin dose increases from ~10.5% to ~1.5% for field-size increases of 5  ×  5 cm(2) to 20  ×  20 cm(2). For 10 MV, skin dose increases by ~6% for a 5  ×  5 cm(2) field, and decreases by ~1.5% for a 20  ×  20 cm(2) field. Furthermore, the proposed reshaped flattening filter increases the dose rate from the current 355 MU min(-1) to 529 MU min(-1) (6 MV) or 604 MU min(-1) (10 MV), while the skin-dose increases by only an additional ~2.6% (all percent increases in skin dose are relative to D max). This study suggests that there is minimal increase in the entrance skin dose and minimal/no decrease in the dose rate of the Alberta longitudinal linac-MR system. The even lower skin dose increase at 10 MV offers further advantages in future designs of linac-MR prototypes.

The effects of a transverse magnetic field on an in-line side-coupled 6 MV linear accelerator are given. The results are directly applicable to a linac-MR system used for real-time image guided adaptive radiotherapy. Our previously designed end-to-end linac simulation incorporated the results from the axisymmetric 2D electron gun program EGN2w. However, since the magnetic fields being investigated are non-axisymmetric in nature for the work presented here, the electron gun simulation was performed using OPERA-3d/SCALA. The simulation results from OPERA-3d/SCALA showed excellent agreement with previous results. Upon the addition of external magnetic fields to our fully 3D linac simulation, it was found that a transverse magnetic field of 6 G resulted in a 45 +/- 1% beam loss, and by 14 G, no electrons were incident on the target. Transverse magnetic fields on the linac simulation produced a highly asymmetric focal spot at the target, which translated into a 13% profile asymmetry at 6 G. Upon translating the focal spot with respect to the target coordinates, profile symmetry was regained at the expense of a lateral shift in the dose profiles. It was found that all points in the penumbra failed a 1%/1 mm acceptance criterion for fields between 4 and 6 G. However, it was also found that the lateral profile shifts were corrected by adjusting the jaw positions asymmetrically.