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Innovations conference 2014   prof peter metcalfe moving towards mri along radiation therapy treatment planning
Moving towards MRI alone radiation therapy 
treatment planning: 
What is the impact of MRI distortion? 
Peter Metcalfe*, Amy Walker, Gary Liney, Lois Holloway 
Centre for Medical Radiation Physics, University of Wollongong 
Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute 
* Acknowledge support from Cancer Institute NSW Clinical Leaders Program
Content 
1. Current MRI/CT in Radiotherapy Planning (RTP) 
2. Challenges to MRI alone RTP 
3. Quantifying MRI distortion 
4. Impact of MRI distortion on RTP 
5. Current X-ray Image Guided Radiation Therapy 
6. MRI for Image Guided Radiation Therapy?
CT 
CT MR 
MRI 
1. Current MRI/CT in RTP
 MRI better soft tissue contrast 
 Process - CT scan + MRI scan 
 Register MR contours to CT (rigid/deformable) 
 Transfer MR contours onto CT data set 
CT MR 
1. Current MRI/CT in RTP 
Courtesy Google Images
2. Challenges to MRI alone RTP 
Figure 1: 3He polarization image showing polarized MR helium 3 diffusion scan (right) fused on a proton-density-weighted MR scan (left). These active 
zones would be the regions of conformal avoidance, defined as low-dose objectives during the radiotherapy treatment planning process. 
 Why do we plan using CT data? 
 CT number to electron density 
 Geometric certainty of CT 
CT MR 
Technology in Cancer Research & Treatment 2013 April 24. Epub ahead of print 
Site-specific Use of MRI in Radiotherapy 
Treatment Planning 
This section reviews clinical trials of sites for which vari-ous 
MRI sequences and analysis methods have been useful 
in cancer management. The sites selected for review cover 
brain, head and neck, breast, lung, prostate and cervix, and 
are not intended to be exhaustive. 
Brain 
Owing to its small size and central location within the mag-net, 
the brain is one of the easiest organs to image well. 
MRI is well established as the superior imaging modality 
for diagnostic purposes when assessing the brain. In the 
brain, MRI often provides better visualization of tumor 
and normal tissue than CT, and hence the target volume for 
high-precision intracranial radiotherapy is commonly delin-eated 
directly on MRI studies (Figure 2). It can be imaged 
in standard diagnostic RF coils usually in the treatment 
position, and its registration to CT is trivial even with dif-ferences 
in position. 
The brain was the first site where MRI was routinely used 
in treatment planning. Routine clinical use of MRI in the 
treatment-planning process of fractionated radiotherapy (RT), 
Figure 2: CT (left) co-registered with a T1-3D-SPGR MRI image set (right). The difference in tumor visualization can be clearly appreciated.
3. Quantifying MRI distortion 
 B field inhomogeneity 
 Non linear gradients 
from RF excitation 
 Displacement of signal 
from actual location 
Apparent signal 
location 
Real signal location
 Sunrise Phantom 
 Poly-ethylene 
 +5830 Vitamin E Capsules 
 length 513 mm 
 diameter 500 mm 
 height 350mm 
Amy Walker 
PhD student 
3. Quantifying MRI distortion
3. Quantifying MRI distortion 
MRI moving couch MRI static couch
Moving couch MRI Static couch MRI 
Centre 
Slice 
Extreme 
slice # 2 
(~216 mm 
from 
phantom 
centre) 
S
4. Impact of MRI distortion on RTP 
 Experimental Method: 
 Measure MRI distortion on phantom 
 Apply distortion map to CT on 
patient images 
 RTP plan on ‘distorted’ CT dataset 
 Plan copied onto ‘undistorted” CT 
 Assess dosimetric impact (e.g. DVH)
* CTV Breast 
* Cont. Breast 
* Lungs 
* Heart 
4. Impact of MRI distortion on RTP 
Superior 
Inferior mm 
 MILXView 
 Coronal 
Acknowledge Jason Dowling CSIRO 
http://aehrc.com/research/biomedical-imaging/software-solutions/milxview
4. Impact of MRI distortion on RTP 
Dosimetric variations: 
 15 breast tangent IMRT treatment plans 
 Plans optimised on distorted data met dose 
criteria when reviewed on original CT 
 Less than 3% variation in PTV coverage 
 OAR dose variations low
Literature 
 Metcalfe P, Liney G, Holloway L, Walker A, Barton M, Delaney G, 
Vinod S, Tome W (2013) 
 ”The potential for an enhanced role 
for MRI in radiation-therapy treatment planning” 
 Technology in Cancer Research and Treatment 
 Review Article 
 12(5) 429-446 
 Speculative
 Walker A, Liney G, Metcalfe P, 
Holloway L (2014) 
 "MRI distortion: considerations for 
MRI based radiotherapy 
treatment planning” 
 Australasian Physical & 
Engineering Sciences in 
Medicine. 
 37 (1), 103-113. 
AAPM 2D phantom 
Philips 1.5 T 60 cm bore scanner-T2 turbo spin echo 
Literature
5. Current X-ray Image Guided Radiation 
Therapy? 
 Fiducial markers 
 Surrogate for soft-tissue 
alignment 
 Then make couch shift 
Courtesy: http://c431376.r76.cf2. 
rackcdn.com/37184/fonc-02-00172-HTML 
/image_m/fonc-02-00172-g003.jpg 
Gold Marker and needle 
Reference Wikipedia images
17 
6. MRI for Image Guided Radiation Therapy? 
Australian MRI-Linac Program 
U Alberta- Rotating Magnet 
Viewray-MRIdian MRI-Cobalt 
U Utrecht-Philips Elekta 
http://www.viewray.com
6. MRI for Image Guided Radiation Therapy? 
 MR-IGRT 
 Prototype at Liverpool Hospital - Ingham (Sydney) 
CT MR 
http://inghaminstitute.org/Mri-linac.html 
 NHMRC Grant Principal Investigators: Paul Keall, Michael Barton and Stuart Crozier
6. MRI for Image Guided Radiation Therapy? 
 Orientation Questions? 
 Inline 
 Electron Focus Effect 
(EFE) 
 Transverse 
 Electron Return Effect 
(ERE)
6. MRI for Image Guided Radiation Therapy? 
 Dosimetry Questions? 
MP512 – Diode Array – 2mm pitch 
Courtesy Maegan Gargett 
PhD student CMRP 
3T MRI of MP512
6. MRI for Image Guided Radiation Therapy? 
Rapid MR 
Imaging 
Real-time 
Position 
Estimation 
Slide adapted from images 
courtesy of Paul Keall, U Sydney 
 Goal 
 Real-time adaptive radiation therapy 
 Accounting for anatomic soft tissue
Questions? 
http://inghaminstitute.Siemens 3T MRI at Liverpool Cancer Care, Sydney org/Mri-linac.html 
Peter Metcalfe email: metcalfe@uow.edu.au

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Innovations conference 2014 prof peter metcalfe moving towards mri along radiation therapy treatment planning

  • 2. Moving towards MRI alone radiation therapy treatment planning: What is the impact of MRI distortion? Peter Metcalfe*, Amy Walker, Gary Liney, Lois Holloway Centre for Medical Radiation Physics, University of Wollongong Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute * Acknowledge support from Cancer Institute NSW Clinical Leaders Program
  • 3. Content 1. Current MRI/CT in Radiotherapy Planning (RTP) 2. Challenges to MRI alone RTP 3. Quantifying MRI distortion 4. Impact of MRI distortion on RTP 5. Current X-ray Image Guided Radiation Therapy 6. MRI for Image Guided Radiation Therapy?
  • 4. CT CT MR MRI 1. Current MRI/CT in RTP
  • 5.  MRI better soft tissue contrast  Process - CT scan + MRI scan  Register MR contours to CT (rigid/deformable)  Transfer MR contours onto CT data set CT MR 1. Current MRI/CT in RTP Courtesy Google Images
  • 6. 2. Challenges to MRI alone RTP Figure 1: 3He polarization image showing polarized MR helium 3 diffusion scan (right) fused on a proton-density-weighted MR scan (left). These active zones would be the regions of conformal avoidance, defined as low-dose objectives during the radiotherapy treatment planning process.  Why do we plan using CT data?  CT number to electron density  Geometric certainty of CT CT MR Technology in Cancer Research & Treatment 2013 April 24. Epub ahead of print Site-specific Use of MRI in Radiotherapy Treatment Planning This section reviews clinical trials of sites for which vari-ous MRI sequences and analysis methods have been useful in cancer management. The sites selected for review cover brain, head and neck, breast, lung, prostate and cervix, and are not intended to be exhaustive. Brain Owing to its small size and central location within the mag-net, the brain is one of the easiest organs to image well. MRI is well established as the superior imaging modality for diagnostic purposes when assessing the brain. In the brain, MRI often provides better visualization of tumor and normal tissue than CT, and hence the target volume for high-precision intracranial radiotherapy is commonly delin-eated directly on MRI studies (Figure 2). It can be imaged in standard diagnostic RF coils usually in the treatment position, and its registration to CT is trivial even with dif-ferences in position. The brain was the first site where MRI was routinely used in treatment planning. Routine clinical use of MRI in the treatment-planning process of fractionated radiotherapy (RT), Figure 2: CT (left) co-registered with a T1-3D-SPGR MRI image set (right). The difference in tumor visualization can be clearly appreciated.
  • 7. 3. Quantifying MRI distortion  B field inhomogeneity  Non linear gradients from RF excitation  Displacement of signal from actual location Apparent signal location Real signal location
  • 8.  Sunrise Phantom  Poly-ethylene  +5830 Vitamin E Capsules  length 513 mm  diameter 500 mm  height 350mm Amy Walker PhD student 3. Quantifying MRI distortion
  • 9. 3. Quantifying MRI distortion MRI moving couch MRI static couch
  • 10. Moving couch MRI Static couch MRI Centre Slice Extreme slice # 2 (~216 mm from phantom centre) S
  • 11. 4. Impact of MRI distortion on RTP  Experimental Method:  Measure MRI distortion on phantom  Apply distortion map to CT on patient images  RTP plan on ‘distorted’ CT dataset  Plan copied onto ‘undistorted” CT  Assess dosimetric impact (e.g. DVH)
  • 12. * CTV Breast * Cont. Breast * Lungs * Heart 4. Impact of MRI distortion on RTP Superior Inferior mm  MILXView  Coronal Acknowledge Jason Dowling CSIRO http://aehrc.com/research/biomedical-imaging/software-solutions/milxview
  • 13. 4. Impact of MRI distortion on RTP Dosimetric variations:  15 breast tangent IMRT treatment plans  Plans optimised on distorted data met dose criteria when reviewed on original CT  Less than 3% variation in PTV coverage  OAR dose variations low
  • 14. Literature  Metcalfe P, Liney G, Holloway L, Walker A, Barton M, Delaney G, Vinod S, Tome W (2013)  ”The potential for an enhanced role for MRI in radiation-therapy treatment planning”  Technology in Cancer Research and Treatment  Review Article  12(5) 429-446  Speculative
  • 15.  Walker A, Liney G, Metcalfe P, Holloway L (2014)  "MRI distortion: considerations for MRI based radiotherapy treatment planning”  Australasian Physical & Engineering Sciences in Medicine.  37 (1), 103-113. AAPM 2D phantom Philips 1.5 T 60 cm bore scanner-T2 turbo spin echo Literature
  • 16. 5. Current X-ray Image Guided Radiation Therapy?  Fiducial markers  Surrogate for soft-tissue alignment  Then make couch shift Courtesy: http://c431376.r76.cf2. rackcdn.com/37184/fonc-02-00172-HTML /image_m/fonc-02-00172-g003.jpg Gold Marker and needle Reference Wikipedia images
  • 17. 17 6. MRI for Image Guided Radiation Therapy? Australian MRI-Linac Program U Alberta- Rotating Magnet Viewray-MRIdian MRI-Cobalt U Utrecht-Philips Elekta http://www.viewray.com
  • 18. 6. MRI for Image Guided Radiation Therapy?  MR-IGRT  Prototype at Liverpool Hospital - Ingham (Sydney) CT MR http://inghaminstitute.org/Mri-linac.html  NHMRC Grant Principal Investigators: Paul Keall, Michael Barton and Stuart Crozier
  • 19. 6. MRI for Image Guided Radiation Therapy?  Orientation Questions?  Inline  Electron Focus Effect (EFE)  Transverse  Electron Return Effect (ERE)
  • 20. 6. MRI for Image Guided Radiation Therapy?  Dosimetry Questions? MP512 – Diode Array – 2mm pitch Courtesy Maegan Gargett PhD student CMRP 3T MRI of MP512
  • 21. 6. MRI for Image Guided Radiation Therapy? Rapid MR Imaging Real-time Position Estimation Slide adapted from images courtesy of Paul Keall, U Sydney  Goal  Real-time adaptive radiation therapy  Accounting for anatomic soft tissue
  • 22. Questions? http://inghaminstitute.Siemens 3T MRI at Liverpool Cancer Care, Sydney org/Mri-linac.html Peter Metcalfe email: metcalfe@uow.edu.au

Editor's Notes

  1. The soft tissue superiority of MRI compared to CT has lead to increased interest into its use for radiotherapy treatment planning. However, the geometric distortions which are associated with MRI have limited its more widespread use for this purpose. Geometric distortions are due to gradient nonlinearities, B0 inhomogeneity and effects from any object being placed within the scanner. This results in a displacement of the signal from where it is observed in the image, compared to where it is actually located within the scanner.
  2. The soft tissue superiority of MRI compared to CT has lead to increased interest into its use for radiotherapy treatment planning. However, the geometric distortions which are associated with MRI have limited its more widespread use for this purpose. Geometric distortions are due to gradient nonlinearities, B0 inhomogeneity and effects from any object being placed within the scanner. This results in a displacement of the signal from where it is observed in the image, compared to where it is actually located within the scanner.
  3. Less than interobserver variation ALL “distorted plans” on original CT data met dose criteria When plans optimised based on distorted data they still met the dose criteria when reviewed on the original CT data Discuss results not significant clinically or statistically (except for the combined lung dose on the incline)
  4. Philips 1.5 T scanner with a 60 cm bore, scanned with a T2 weighted turbo spin echo sequence