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Magnetic Resonance-guided radiotherapy (MRgRT) marks the beginning of a new era. MR is a versatile and suitable imaging modality for radiotherapy, as it enables direct visualization of the tumor and the surrounding organs at risk. Moreover, MRgRT provides real-time imaging to characterize and eventually track anatomical motion. Nevertheless, the successful translation of new technologies into clinical practice remains challenging. To date, the initial availability of next-generation hybrid MR-linac (MRL) systems is still limited and therefore, the focus of the present preview was on the initial applicability in current clinical practice and on future perspectives of this new technology for different treatment sites. MRgRT can be considered a groundbreaking new technology that is capable of creating new perspectives towards an individualized, patient-oriented planning and treatment approach, especially due to the ability to use daily online adaptation strategies. Furthermore, MRL systems overcome the limitations of conventional image-guided radiotherapy, especially in soft tissue, where target and organs at risk need accurate definition. Nevertheless, some concerns remain regarding the additional time needed to re-optimize dose distributions online, the reliability of the gating and tracking procedures and the interpretation of functional MR imaging markers and their potential changes during the course of treatment. Due to its continuous technological improvement and rapid clinical large-scale application in several anatomical settings, further studies may confirm the potential disruptive role of MRgRT in the evolving oncological environment.

The integration of magnetic resonance imaging (MRI) for guidance in external beam radiotherapy has faced significant research and development efforts in recent years. The current availability of linear accelerators with an embedded MRI unit, providing volumetric imaging at excellent soft tissue contrast, is expected to provide novel possibilities in the implementation of image-guided adaptive radiotherapy (IGART) protocols. This study reviews open medical physics issues in MR-guided radiotherapy (MRgRT) implementation, with a focus on current approaches and on the potential for innovation in IGART. Daily imaging in MRgRT provides the ability to visualize the static anatomy, to capture internal tumor motion and to extract quantitative image features for treatment verification and monitoring. Those capabilities enable the use of treatment adaptation, with potential benefits in terms of personalized medicine. The use of online MRI requires dedicated efforts to perform accurate dose measurements and calculations, due to the presence of magnetic fields. Likewise, MRgRT requires dedicated quality assurance (QA) protocols for safe clinical implementation. Reaction to anatomical changes in MRgRT, as visualized on daily images, demands for treatment adaptation concepts, with stringent requirements in terms of fast and accurate validation before the treatment fraction can be delivered. This entails specific challenges in terms of treatment workflow optimization, QA, and verification of the expected delivered dose while the patient is in treatment position. Those challenges require specialized medical physics developments towards the aim of fully exploiting MRI capabilities. Conversely, the use of MRgRT allows for higher confidence in tumor targeting and organs-at-risk (OAR) sparing. The systematic use of MRgRT brings the possibility of leveraging IGART methods for the optimization of tumor targeting and quantitative treatment verification. Although several challenges exist, the intrinsic benefits of MRgRT will provide a deeper understanding of dose delivery effects on an individual basis, with the potential for further treatment personalization.

Background MR‐guided radiotherapy (MRgRT) offers new opportunities but also introduces workflow complexities requiring dedicated optimization. Implementing magnetic resonance linear accelerator (MR‐Linac) technology comes with challenges such as prolonged treatment times and workflow integration issues. Purpose We present here our experience and share practical tips and tricks to streamline MR‐Linac implementation, optimize workflow efficiency, and improve coordination. Methods The first 150 patients treated with a 1.5T MR‐Linac Unity® at our institution were analyzed. Treatments were assessed based on session recordings, difficulties encountered were identified, and solutions documented. Results A total of 726 fractions were delivered, with a mean treatment time of 48 minutes. Key optimizations included standardized operating procedures (SOPs) and structured briefing sheets, leading to reduced delays and improved treatment consistency. Conclusion Strategic workflow standardization and optimized communication tools significantly improved the ability to deliver high‐quality, patient‐centered care by streamlining processes and enhancing coordination among team members. These insights provide practical guidance for centers integrating MR‐Linac technology.

Background and purpose In pancreatic radiotherapy, residual tumor motion during treatment increases the risk of toxicity. Cine imaging acquired during magnetic resonance guided radiotherapy (MRgRT) enables real‐time treatment gating in response to anatomical motion, which can reduce this risk; however, treatment gating can negatively impact the efficiency of treatment. This study aimed to quantify the extent of residual tumor motion during breath hold and evaluate the appropriateness of the treatment gating margins used in current clinical practice. Materials and methods Cine imaging acquired during pancreatic MRgRT of 11 patients on the ViewRay MRIdian was analyzed. The total duration of treatment analyzed was 12 h 13 min. Improved methods for processing and analyzing cine imaging were developed: breath holds were systematically separated with frequency analysis, residual motion was measured with consideration of both the tracking structure contour and centroid, and residual motion measurements were supported by phantom measurements of image scaling, resolution, and noise. Residual motion was measured at angles 0°, 45°, 90°, and 135° to the superior‐inferior (SI) direction. Total residual motion was measured by combining directional measurements. Results The minimum tracking structure displacement resolvable through cine imaging was found to be 1.5 mm; therefore, residual motion analysis was limited to 1.5 mm spatial resolution. Total residual motion was contained within margins Δ= $\\Delta =\\, $ ±1.5, ±3, and ±4.5mm with mean percentage frequencies of 97.0%, 91.1%, and 67.8%. Most residual motion was observed in the SI direction, and significantly more residual motion was measured for the tracking structure contour than the centroid. Conclusion The results demonstrate that patients are largely able to maintain breath hold positions to within a 3 mm margin, thus provide evidence that supports the use of a 3mm gating margin in clinical practice. Residual motion frequently exceeded 1.5 mm so a reduction in gating margin would have an undesirable impact on treatment efficiency.

Purpose Magnetic Resonance‐guided radiotherapy (MRgRT) systems allow continuous monitoring of therapy volumes during treatment delivery and personalized respiratory gating approaches. Treatment length may therefore be significantly affected by patient’s compliance and breathing control. We quantitatively analyzed treatment process time efficiency (TE) using data obtained from real‐world patient treatment logs to optimize MRgRT delivery settings. Methods Data corresponding to the first 100 patients treated with a low T hybrid MRI‐Linac system, both in free breathing (FB) and in breath hold inspiration (BHI) were collected. TE has been computed as the percentage difference of the actual single fraction’s total treatment time and the predicted treatment process time, as computed by the TPS during plan optimization. Differences between the scheduled and actual treatment room occupancy time were also evaluated. Finally, possible correlations with planning, delivery and clinical parameters with TE were also investigated. Results Nine hundred and nineteen treatment fractions were evaluated. TE difference between BHI and FB patients’ groups was statistically significant and the mean TE were 42.4%, and −0.5% respectively. No correlation was found with TE for BHI and FB groups. Planning, delivering and clinical parameters classified BHI and FB groups, but no correlation with TE was found. Conclusion The use of BHI gating technique can increase the treatment process time significantly. BHI technique could be not always an adequate delivery technique to optimize the treatment process time. Further gating techniques should be considered to improve the use of MRgRT.

Purpose To describe and characterize daily machine quality assurance (QA) for an MR‐guided radiotherapy (MRgRT) linac system, in addition to reporting a longitudinal assessment of the dosimetric and mechanical stability over a 7‐month period of clinical operation. Methods Quality assurance procedures were developed to evaluate MR imaging/radiation isocenter, imaging and patient handling system, and linear accelerator stability. A longitudinal assessment was characterized for safety interlocks, laser and imaging isocenter coincidence, imaging and radiation (RT) isocentricity, radiation dose rate and output, couch motion, and MLC positioning. A cylindrical water phantom and an MR‐compatible A1SL detector were utilized. MR and RT isocentricity and MLC positional accuracy was quantified through dose measured with a 0.40 cm2 x 0.83 cm2 field at each cardinal angle. The relationship between detector response to MR/RT isocentricity and MLC positioning was established through introducing known errors in phantom position. Results Correlation was found between detector response and introduced positional error (N = 27) with coefficients of determination of 0.9996 (IEC‐X), 0.9967 (IEC‐Y), 0.9968 (IEC‐Z) in each respective shift direction. The relationship between dose (DoseMR/RT+MLC) and the vector magnitude of MLC and MR/RT positional error (Errormag) was calculated to be a nonlinear response and resembled a quadratic function: DoseMR/RT+MLC[%] = −0.0253 Errormag [mm]2 − 0.0195 Errormag [mm]. For the temporal assessment (N = 7 months), safety interlocks were functional. Laser coincidence to MR was within ±2.0 mm (99.6%) and ±1.0 mm (86.8%) over the 7‐month assessment. IGRT position–reposition shifts were within ±2.0 mm (99.4%) and ±1.0 mm (92.4%). Output was within ±3% (99.4%). Mean MLC and MR/RT isocenter accuracy was 1.6 mm, averaged across cardinal angles for the 7‐month period. Conclusions The linac and IGRT accuracy of an MR‐guided radiotherapy system has been validated and monitored over seven months for daily QA. Longitudinal assessment demonstrated a drift in dose rate, but temporal assessment of output, MLC position, and isocentricity has been stable.

Purpose The purpose of this work was to experimentally quantify MR‐compatible ionization chamber response for 1.5T Elekta Unity and 0.35T ViewRay MRIdian MR‐linac systems through the determination of the magnetic field quality conversion factor, kB,Q. Methods Seven MR‐compatible ionization chamber models from Standard Imaging and PTW were evaluated. Both the quality conversion factor kQ and the magnetic field quality conversion factor kB,Q were experimentally determined through a cross‐calibration method. Specifically, the ratio of absorbed dose measured with a reference A1SL chamber under reference conditions to corrected output measured with each test chamber at the same point of measurement allowed for the determination of kB,Q. The angular dependence of the magnetic field quality conversion factor for MR‐compatible chamber models was assessed for the 1.5T Elekta Unity system by measuring kB,Q with the chamber axis and magnetic field direction aligned at cardinal angles (0°, 90°, 180°, 270°). Results Beam quality conversion (kQ) factors for MR‐compatible ionization chambers measured in a standard linac beam showed an average percent difference of −0.09 ± 0.18% compared to computed kQ values for their conventional chamber versions. Similarly, magnetic field quality conversion (kB,Q) factors for corresponding MR and non‐MR ionization chamber models measured using the same cross‐calibration technique demonstrated average percent differences of −0.1 ± 0.3% and 0.0 ± 0.2% for the Elekta Unity and ViewRay MRIdian, respectively. Investigation of the angular dependence of this correction factor demonstrated identical chamber response for equivalent MR‐compatible and conventional chamber models. Conclusions This work provides critical experimental validation of MR‐compatible ionization chamber performance, with a direct comparison of measured kB,Q values to corresponding conventional chamber models demonstrating nearly equivalent chamber response. kB,Q values determined using our experimental method will serve as an important reference for upcoming MR‐linac reference dosimetry protocols and ultimately represent an important step towards accurate output calibration of MR‐linac systems.

Purpose MR‐guided radiotherapy with high accuracy treatment planning requires addressing MR imaging artifacts that originate from system imperfections. This work presents the characterization and corresponding correction of gantry‐related imaging distortions including geometric distortion and isocenter shift in a 0.35 T magnetic resonance imaging (MRI)‐guided radiotherapy (MRgRT) system using distortion vector fields (DVFs). Methods Two phantoms, the magnetic resonance imaging distortion in 3D (MRID3D) phantom and the Fluke phantom, along with a human volunteer were imaged at different gantry angles on a 0.35 T MR‐Linac. The geometric distortion and isocenter shift were characterized for both phantom images. DVFs with a field of view extended beyond the physical boundary of the MRID3D phantom were extracted from images taken at 30° gantry angle increments, with vendor‐provided distortion correction turned on and off (DstOff). These extended DVFs were then applied to the relevant phantom images to correct their geometric distortions and isocenter shift at the respective gantry angles. The extended DVFs produced from the MRID3D phantom were also applied to Fluke phantom and human MR images at their respective gantry angles. The resampled images were evaluated using structural similarity index measure (SSIM) comparison with the vendor corrected images from the MRgRT system. Results Geometric distortion with “mean (± SD) distortion” of 3.2 ± 0.02, 2.9 ± 0.02, and 1.8 ± 0.01 mm and isocenter shift (±SD) of 0.49 ± 0.3, 0.05 ± 0.2, and 0.01 ± 0.03 mm were present in the DstOff MRID3D phantom images in right–left (RL), anterior–posterior (AP), and superior–inferior (SI) directions, respectively. After resampling the originally acquired images by applying extended DVFs, the distortion was corrected to 0.18 ± 0.02, 0.09 ± 0.01, 0.15 ± 0.01 mm, and isocenter shift was corrected to 0.14 ± 0.05, −0.02 ± 0.04, and −0.07 ± 0.05 mm in RL, AP, and SI directions, respectively. The Fluke phantom average geometric distortion with “mean (± SD) distortion” of 2.7 ± 0.1 mm was corrected to 0.2 ± 0. 1 mm and the average isocenter shift (± SD) of 0.51 ± 0.2 mm, and 0.05 ± 0.03 was corrected to −0.08 ± 0.03 mm, and −0.05 ± 0.01 in RL and AP directions, respectively. SSIM (mean ± SD) of the original images to resampled images was increased from 0.49 ± 0.02 to 0.78 ± 0.01, 0.45 ± 0.02 to 0.75 ± 0.01, and 0.86 ± 0.25 to 0.98 ± 0.08 for MRID3D phantom, Fluke phantom, and human MR images, respectively, for all the gantry angles compared to the vendor corrected images. Conclusion The gantry‐related MR imaging distortion including geometric distortion and isocenter shift was characterized and a corresponding correction was demonstrated using extended DVFs on 0.35 T MRgRT system. The characterized gantry‐related isocenter shift can be combined with geometric distortion correction to provide a technique for the correction of the full system‐dependent distortion in an MRgRT system.

Purpose Magnetic resonance‐guided adaptive radiotherapy (MRgART) is considered a promising resource for pancreatic cancer, as it allows to online modify the dose distribution according to daily anatomy. This study aims to compare the dosimetric performance of a simplified optimizer implemented on a MR‐Linac treatment planning system (TPS) with those obtained using an advanced optimizer implemented on a conventional Linac. Methods Twenty patients affected by locally advanced pancreatic cancer (LAPC) were considered. Gross tumor volume (GTV) and surrounding organ at risks (OARs) were contoured on the average 4DCT scan. Planning target volume was generated from GTV by adding an isotropic 3 mm margin and excluding overlap areas with OARs. Treatment plans were generated by using the simple optimizer for the MR‐Linac in intensity‐modulated radiation therapy (IMRT) and the advanced optimizer for conventional Linac in IMRT and volumetric modulated arc therapy (VMAT) technique. Prescription dose was 40 Gy in five fractions. The dosimetric comparison was performed on target coverage, dosimetric indicators, and low dose diffusion. Results The simplified optimizer of MR‐Linac generated clinically acceptable plans in 80% and optimal plans in 55% of cases. The number of clinically acceptable plans obtained using the advanced optimizer of the conventional Linac with IMRT was the same of MR‐Linac, but the percentage of optimal plans was higher (65%). Using the VMAT technique, it is possible to obtain clinically acceptable plan in 95% and optimal plans in 90% of cases. The advanced optimizer combined with VMAT technique ensures higher target dose homogeneity and minor diffusion of low doses, but its actual optimization time is not suitable for MRgART. Conclusion Simplified optimization solutions implemented in the MR‐Linac TPS allows to elaborate in most of cases treatment plans dosimetrically comparable with those obtained by using an advanced optimizer. A superior treatment plan quality is possible using the VMAT technique that could represent a breakthrough for the MRgART if the modern advancements will lead to shorter optimization times.

Introduction Aim of this study is to dosimetrically characterize a new inorganic scintillator designed for magnetic resonance‐guided radiotherapy (MRgRT) in the presence of 0.35 tesla magnetic field (B). Methods The detector was characterized in terms of signal to noise ratio (SNR), reproducibility, dose linearity, angular response, and dependence by energy, field size, and B orientation using a 6 MV magnetic resonance (MR)‐Linac and a water tank. Field size dependence was investigated by measuring the output factor (OF) at 1.5 cm. The results were compared with those measured using other detectors (ion chamber and synthetic diamond) and those calculated using a Monte Carlo (MC) algorithm. Energy dependence was investigated by acquiring a percentage depth dose (PDD) curve at two field sizes (3.32 × 3.32 and 9.96 × 9.96 cm2) and repeating the OF measurements at 5 and 10 cm depths. Results The mean SNR was 116.3 ± 0.6. Detector repeatability was within 1%, angular dependence was <2% and its response variation based on the orientation with respect to the B lines was <1%. The detector has a temporal resolution of 10 Hz and it showed a linear response (R2 = 1) in the dose range investigated. All the OF values measured at 1.5 cm depth using the scintillator are in accordance within 1% with those measured with other detectors and are calculated using the MC algorithm. PDD values are in accordance with MC algorithm only for 3.32 × 3.32 cm2 field. Numerical models can be applied to compensate for energy dependence in case of larger fields. Conclusion The inorganic scintillator in the present form can represent a valuable detector for small‐field dosimetry and periodic quality controls at MR‐Linacs such as dose stability, OFs, and dose linearity. In particular, the detector can be effectively used for small‐field dosimetry at 1.5 cm depth and for PDD measurements if the field dimension of 3.32 × 3.32 cm2 is not exceeded.