Alberto Torresin

M. Minella, A. Moscato, P.E. Colombo

Requirements to MRI and MRS data to be

applicable for radiation treatment
Struttura Complessa di Fisica Sanitaria
Azienda Ospedale Niguarda Ca Granda, Milano
Universit degli Studi di Milano Dip. di Fisica
EFOMP: Scientific Committee (chair)
email: alberto.torresin@unimi.it
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Start up
To clarify some terminologies: important for communication.

The Big Tower of Babele, Brueghel, 1563, Vienna, Kunsthistorishes Museum

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Summary

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 What do we treat?
Radiotherapy Treatment Planning System (RTPS):
requirements
State of art: new treatments
Image integration: requirements
State of art. Imaging in radiotherapy: image planning
State of art. Imaging in radiotherapy: treatment
verification by imaging
MRI Scanner technology
Image registration
Advanced MRI images for RTPS
Future trends: hybrid system
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What do we treat?

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 The goal of modern Radiotherapy is to deliver a

lethal amount of energy to the tumor while sparing
surrounding healthy tissue.
The future may lie in biologically guided radiation
therapy, in which morphological and functional
imaging is used to characterize tissue biological
function.
Today: MRI is now an important morphological and
functional imaging able to open new diagnostic and
planning scenario

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 Radiation therapy has a long history of making use

of advancements in technology with the goal of
improving patient care, in fact since the discovery
of the x-ray by Roentgen in 1895.
The International Commission of Radiation Units
(ICRU) established several important definitions in
order to obtain a common vocabulary among
radiotherapists in tumor volume delineation.

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Tumor volume delineation

GTV-Gross Tumor Volume:
The visible or
tumor volume;

palpable

CTV-Clinical Target Volume:

GTV+margin for sub clinical
tumor spread;

PTV-Planning
Volume:
CTV+margins for
inaccuracy
and
movements.

Target
setup
organ

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 Accurate margins around the GTV are

relevant.
The choice of margins is important for the
therapeutic ratio.
Too small margins may result in an
underdosage of part of the target volume
A relatively minor increase of margins may
result in a significant reduction of sparing of
healthy tissue

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Radiotherapy Treatment
Planning System (RTPS):
requirements

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Radiotherapy Treatment
Planning System (RTPS)
RTPS is the system able to calculate the
energy distribution- dose [Gy= J/kg]
inside the human body using specific and
complex physics algorithm.

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Radiotherapy Treatment
Planning System (RTPS)
Hardware and Software by which a team
(radiation oncologists, radiation therapist, and
medical physicists) plan the appropriate external
beam or internal treatment technique in order to
predict the patient dose distribution.
Typically, medical imaging are used to create a
virtual patient for a computer-aided design
procedure.

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Radiotherapy Treatment
Planning System (RTPS)
RTPS requires different types of images:

Computed Tomography (CT),

MRI,
2D/3D angiography,
Ultrasound (US).

Any image needs a calibration in terms of electron

density and geometrical reconstruction before a
clinical use in a RTPS.

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Early 1980

Late 1980
Today
B. A. Fraass, J. M. Moran, PhDSemin Radiat Oncol 22:3-10, 2012

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State of art:
new treatments

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New trends in Radiotherapy

IMRT

(Intensity
Modulated
RadioTherapy) with photons
Volumetric
Modulated Arc
Therapy (VMAT, RapidArc)

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Image-Guided RadioTherapy (IGRT)

Day by day patient uncertainties:
deformation of the soft tissues
patient set-up
geometric variations of the tumor
breathing, and physiological movements

IGRT ensures that target position during

treatment is the same of the treatment plan
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Tumor Motion During

Breathing
tumor motion is complex

Tumor
Cross-sectional View
of Patients Chest

Some motion is mostly

Anterior / Posterior

Tumor

Some motion is mostly

Superior / Inferior

All tumor motion

is Complex

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CT

Patient positioning

CT scanning

MR

Localization/marking

Patient positioning

MR scanning

Delineation

Fusion
Delineation

Dosimetry

Streamlined workflow
for Therapy Planning
with CT and MR
From Philips

DRR creation

Patient positioning

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Treatment

Image integration:
requirements

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DIAGNOSTIC Imaging
CT

VERIFICATION Imaging
Record & Verify
MRI

NM

angio
X ray

PLANNING Imaging
simul
ator

clinical
workstation

treatment
planning
system

VERIFICATION
Imaging
portal
imaging
EPID

DRR

film
CR
CT

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Imaging
We need all the technical support to define
the tumor geometry inside the clinical
control

Why CT?
Why MR?
Why CT/PET?
Registration technique
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Imaging in RT Planning
Why CT?
Electron density
Geometrical accuracy
Readily available
Poor soft-tissue contrast
Ionising radiation
dose delivery to patient

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Imaging in RT Planning
Why MRI ?

Very good soft-tissue contrast

Non-ionising radiation
Functional imaging
Unrestricted multiplanar
Volumetric imaging
No dose delivery to patient

No electron density
Cost & availability
Geometrical distortion
Necessity of image registration with CT
images
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MRI-based targets
To compare CT and MRI target volumes

EMAMI et al. Int. J. Radiation Oncology Biol. Phys., 57, 2003

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MR in Radiation Oncology
Gold standard for soft tissue contrast
MR image (T1 with gadolinium
contrast). The white area in
the brain is the contrast uptake.
The CT defined
superimposed on
image.

tumor is
the MR

A clear disagreement is shown.

Kristensen BH et al.,
Radiother Oncol. 2008 Apr;87(1):100-9.

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State of art.
Imaging in radiotherapy:
image planning

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Minimum Requirements for

CT scanner in Radiotherapy

large bore of the scanner,

flat table,
laser for patients positioning,
patients immobilization devices,
breath management.

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State of art.
Imaging in radiotherapy:
treatment verification by imaging

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Elekta

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Varian

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Cyberknife (Accuray)
RX source

FPD

6 MV robotic linac with 1200 possible beam

orientations
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50cm

85cm SAD

TOMOTHERAPY

40 cm
FOV

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VERO Mitsubishi Heavy Industries C band

Linac integrated with a 4D-IGRT system

2 sets of kV X-ray tubes and

flat panel detectors:
- stereoscopic radiographic
imaging
- cone-beam CT
- real-time fluoroscopic
monitoring during irradiation

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State of art:
imaging in radiotherapy:
treatment verification by imaging
The standard technology:
at the moment no MRI are on line image
for tumor control during the treatment

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MRI Scanner technology

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Minimum Requirements for

MRI scanner in Radiotherapy
For Radiotherapy the Uniformity of
magnetic field (1.5T, 3T) is important (over
40 cm sphere diameter).
Image
distortion
is
an
important
consideration in the use of magnetic
resonance (MR) images for radiotherapy
planning.
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Minimum Requirements for

MRI scanner in Radiotherapy
Breath management
Flat tabletop insert during the MR imaging is
mandatory

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Scanner technology
For patients immobilisation devices able to
maintain the RT position
Open MRI is better for patient positioning
Wide bore

Laser for patients position for RT plan

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Scanner technology
RF Coil Characteristic may have different SNR (Signal to
noise ratio)
By Andrew Beavis
Suface coil
Head coil
Body coil

Surface coil
Excellent SNR
Poor Uniformity

Bodycoil
Poor SNR
Excellent Uniformity

RF Coil (Surface, Head, Body) characteristic should have

optimized; dedicated coils for radiotherapy should be used
were the quality for this specific application must be
optimized;
copromise
characteristic
(quality/RT
application)
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Open MRI: an opportunity

Flat table
Laser
Coils for RT

From Philips

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From Philips

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Geometrical Distorsion
Geometrical distortion:
GD%=100 * Max ([(Li-Lnom)/ Lnom];
[(Di-Dnom)/Dnom])
Where Lnon and Dnom: nominal values

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Geometrical Distorsion
Systematic Distortion
introduced by the patient; mitigated by right
sequences.

System Distortion

Scanners have in-build 2D (3D) correction

Bo localised shimming
More problematic at edges of large FOV
EPI: severe distortion

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Geometrical Distorsion (EPI)

GD% using the same EPI sequence:

MRI system(a) :3.2%,
MRI system(b) :3.6%,
MRI system(c) :0.7%

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Geometric Distortion
It is important to measure geometrical accuracy of
the system
Radiotherapy requires a positional accuracy of order
2mm
GD increases with increasing FOV

Susceptibility-induced Distortion in the Brain: patients depending

Sagittal Gradient-echo

Sagittal EPI
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Geometrical Distorsion
Range from typically 0.2 to 5 mm as the distance
from the centre of the magnetic field increases
from 5 to 10 cm (Prott et al, 2000)
Prott et al, 2000 investigated 27 MRI units. The
distortions were found to cause small variations in
maximum dose (0.5%).
ICRU reports suggested a dose uniformity inside
the PTV from -5% to +7% for 3DCRT.

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Different approaches
concerning the MRI GD
Tanner et al (2000) results show
that the scanner and the phantoms
used in measuring distortion give
highly reproducible results with
mean changes of the order of 0.1
mm
between
repeated
measurements of marker positions
in the same imaging session.

This phantom was designed to characterize system

distortions

The Tanners work has demonstrated

that this distortion could be measured
and corrected
Tanner et al. PMB 45, 2117, 2000
An uncorrected coronal image acquired from the linearity
test object.
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Image registration

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Registration technique
Frame based methods
Frame less method
Rigid registration
Surface, bone
Anatomic or external markers

Deformable registration
Mutual Information
Quality assurance procedures of CT and MR image
registration are mandatory

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Oncology Configuration
Cervical cancer

Automated rigid
registration
No manual
adaptations
Matching body
contours

MR image:
T2W-TSE-HR

MR female pelvis

CT female pelvis

Courtesy: St. Lukes E. Hospital, Houston, USA

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Advanced MRI images for

RTPS

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 Magnetic Resonance Spectroscopy (MRS), functional MRI

(fMRI), Diffusion Tensor Imaging-Fiber Tracking (DTIFT) are now applied in Radiotherapy for dose calculation
after images registration with the reference CT images.
The RTPS workstations cant generally manage advanced
MRI images, so image transferring from other computer
system to them is needed.
This transfer is not generally easy and different technical problems
must be solved: data format transformation (DICOM standard
format may not be in each data set of Advanced MRI) and
integration of the advanced MR images with the RTPS reference
images.

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MRI and Brachytherapy

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Brachytherapy
Brachytherapy is a form of
radiotherapy in which the
sealed radiation source is
close to the tissues to be
treated (target volume).

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Brachytherapy Device
Titianium construction and
plastic ring cap
Distorsion and RF heating
neglegible
Susceptibility artefact nedds
to be considered
Orientation of the device
Careful consideration of
scan protocol

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Brachytherapy Device

UCSF Comprehensive Cancer Center - San Francisco

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MRI and Radiosurgery

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fMRI nd DTI
To avoid some region when
RT plan is applied (the
same avoid experience
used in neurosurgery)
Some technical problems to
send fMRI and DTI to
RTPS

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3D reconstruction using GK RTPS in a case of astrocytoma.

In blue motor tract fibbers, in violet granulocytic astrocytoma.
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In blue line contour motor tract fibbers, in yellow line contour

marginal prescription isodose to the tumor.
(Without attenuation correction)
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MRS: MR Spectroscopy
Helpful approach to define tumor target
definition for RTPS and to evaluate
response and recurrence
The application of MRS in Radiotherapy
needs a registration with reference image for
dose evaluation made by RTPS.

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MRS: MR Spectroscopy
Can isolate voxels of information
Metabolism maps

1H

MRS:

Tumor

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PET and MRI for planning in

Radiotherapy
Functional imaging with
18F fluorodeoxyglucose (FDG) positron emission
tomography (PET),
MRI

combined with CT (FDG-PET/CT)

gives additional functional information to define
the shape and the size of GTV

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PET and MRI for planning in

Radiotherapy

Jansen et al. Int. J. Radiation Oncology Biol. Phys. 2012

The node is indicated with white arrows (fig. A and C).

(A) coronal T1-weighted image,

(B) axial STIR with 1H-MRS voxel overlaid
(B) in red The voxel of interest for 1H-MRS is indicated
(C) axial T1-weighted postcontrast MR images.
(D) the corresponding [18F]FDG intensity map is shown overlaid on a CT:
[18F]FDG uptake in the node.
(E) the localized 1H-MR spectrum from the node of patient is displayed
(F) the LCModel analysis of the spectrum, highlighting
Cho resonance is presented
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Future trends: hybrid system

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Imaging: PET/MRI

Zaidi, Del Guerra, Med. Phys. 38 (10), October 2011

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1- MRI guided Radiation Therapy

MR scanner /60Co
high field MRI system
three sources: ~220 TBq(~ 6000 Ci)
http://www.viewray.com

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2- MRI and LINAC

University Hospital of Umea
Karlsson M. et al. Int. J. Radiation Oncology Biol. Phys. 2009

1.5 T MRI unit with a 70-cm-bore size was

installed close to a linear accelerator,
special trolley was developed to transport patients,
who were fixed in advance, between the MRI unit
and the accelerator

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2- MRI and LINAC

1.5-T Siemens Espree unit
Siemens ONCOR (LINAC)

Karlsson M. et al. Int. J. Radiation Oncology Biol. Phys. 2009

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3- MR LINAC
A prototype of hybrid system is a joint effort between:
the Radiotherapy Department of the University of Utrecht
Elekta (Crawley, U.K.)
Philips Research (Hamburg, Germany).

new integration between 1.5 T MRI functionality and a

6MV linear accelerator
high precision radiation dose delivery, based on diagnostic
quality MR images.
No degradation of the performance of either system was
found
Both of them operate independently
Gating and tracking strategies are most effective in cases
where anatomic motion can be visualized directly and an
integrated MRI accelerator is able to support them
Lagendijka JW et al. Oncology, 2008
Raaymakers BW et al, Phys. Med. Biol. 2009
Crijns SPM et al, Phys. Med. Biol. 2012

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3- MR LINAC

Lagendijka JW et al. Oncology, 2008

Raaymakers BW et al, Phys. Med. Biol. 2009
Crijns SPM et al, Phys. Med. Biol. 2012

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MR

Patient positioning

Delineation/
segmentation

Density
assignment

Dose calculation

Workflow for MR-only sim, without

CT registration
.. density correction..WIP
From Philips

MR scanning

Localization/marking

DRR creation

Patient positioning

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Treatment

Conclusion
The concept of image is still in progress,
following the evolution of human body
knowledge
The combination of information from
complementary imaging modalities is
expected to have a great benefit in patient
treatment.
This fact is particularly relevant for target
definition, which remains, one of the most
important sources of error in Radiotherapy.
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Conclusion
Anatomical imaging with CT and MRI
produces different GTV volumes.
Functional imaging with modalities such as
MRI and PET will generally reveal an even
different volume.
The solutions of these new problems are in
progress and a lot of researches in clinical
applications are in discussion.

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