Numerous patients have been treated with MRidian as part of a clinical trial or in routine clinical practice. This has led to several peer reviewed scientific publications. Hereby a non-exhaustive list of published data.
A GPU‐accelerated Monte Carlo dose calculation platform and its application toward validating an MRI‐guided radiation therapy beam model.
Wang, Yuhe (2016)
The clinical commissioning of IMRT subject to a magnetic field is challenging. The purpose of this work is to develop a GPU-accelerated Monte Carlo dose calculation platform based on penelope and then use the platform to validate a vendor-provided MRIdian head model toward quality assurance of clinical IMRT treatment plans subject to a 0.35 T magnetic field.
penelope was first translated from fortran to c++ and the result was confirmed to produce equivalent results to the original code. The c++ code was then adapted to cuda in a workflow optimized for GPU architecture. The original code was expanded to include voxelized transport with Woodcock tracking, faster electron/positron propagation in a magnetic field, and several features that make gpenelope highly user-friendly. Moreover, the vendor-provided MRIdian head model was incorporated into the code in an effort to apply gpenelope as both an accurate and rapid dose validation system. A set of experimental measurements were performed on the MRIdian system to examine the accuracy of both the head model and gpenelope. Ultimately, gpenelope was applied toward independent validation of patient doses calculated by MRIdian's kmc.
An acceleration factor of 152 was achieved in comparison to the original single-thread fortran implementation with the original accuracy being preserved. For 16 treatment plans including stomach (4), lung (2), liver (3), adrenal gland (2), pancreas (2), spleen(1), mediastinum (1), and breast (1), the MRIdian dose calculation engine agrees with gpenelope with a mean gamma passing rate of 99.1% ± 0.6% (2%/2 mm).
A Monte Carlo simulation platform was developed based on a GPU- accelerated version of penelope. This platform was used to validate that both the vendor-provided head model and fast Monte Carlo engine used by the MRIdian system are accurate in modeling radiation transport in a patient using 2%/2 mm gamma criteria. Future applications of this platform will include dose validation and accumulation, IMRT optimization, and dosimetry system modeling for next generation MR-IGRT systems.
Longitudinal diffusion MRI for treatment response assessment: Preliminary experience using an MRI-guided tri-cobalt 60 radiotherapy system.
Yang, Y., Cao, M., Sheng, K., Gao, Y., Chen, A., Kamrava, M., ... & Low, D. (2016)
To demonstrate the preliminary feasibility of a longitudinal diffusion magnetic resonance imaging (MRI) strategy for assessing patient response to radiotherapy at 0.35 T using an MRI-guided radiotherapy system (ViewRay).
Six patients (three head and neck cancer, three sarcoma) who underwent fractionated radiotherapy were enrolled in this study. A 2D multislice spin echo single-shot echo planar imaging diffusion pulse sequence was implemented on the ViewRay system and tested in phantom studies. The same pulse sequence was used to acquire longitudinal diffusion data (every 2–5 fractions) on the six patients throughout the entire course of radiotherapy. The reproducibility of the apparent diffusion coefficient (ADC) measurements was assessed using reference regions and the temporal variations of the tumor ADC values were evaluated.
In diffusion phantom studies, the ADC values measured on the ViewRay system matched well with reference ADC values with <5% error for a range of ground truth diffusion coefficients of 0.4–1.1 × 10−3 mm2/s. The remote reference regions (i.e., brainstem in head and neck patients) had consistent ADC values throughout the therapy for all three head and neck patients, indicating acceptable reproducibility of the diffusion imaging sequence. The tumor ADC values changed throughout therapy, with the change differing between patients, ranging from a 40% drop in ADC within the first week of therapy to gradually increasing throughout therapy. For larger tumors, intratumoral heterogeneity was observed. For one sarcoma patient, postradiotherapy biopsy showed less than 10% necrosis score, which correlated with the observed 40% decrease in ADC from the fifth fraction to the eighth treatment fraction.
This pilot study demonstrated that longitudinal diffusion MRI is feasible using the 0.35 T ViewRay MRI. Larger patient cohort studies are warranted to correlate the longitudinal diffusion measurements to patient outcomes. Such an approach may enable response-guided adaptive radiotherapy.
A software tool to automatically assure and report daily treatment deliveries by a Cobalt-60 radiation therapy device.
Yang, Deshan (2016)
Journal of Applied Clinical Medical Physics
The aims of this study were to develop a method for automatic and immediate verification of treatment delivery after each treatment fraction in order to detect and correct errors, and to develop a comprehensive daily report which includes delivery verification results, daily image-guided radiation therapy (IGRT) review, and information for weekly physics reviews. After systematically analyzing the requirements for treatment delivery verification and understanding the available information from a commercial MRI-guided radiotherapy treatment machine, we designed a procedure to use 1) treatment plan files, 2) delivery log files, and 3) beam output information to verify the accuracy and completeness of each daily treatment delivery. The procedure verifies the correctness of delivered treatment plan parameters including beams, beam segments and, for each segment, the beam-on time and MLC leaf positions. For each beam, composite primary fluence maps are calculated from the MLC leaf positions and segment beam-on time. Error statistics are calculated on the fluence difference maps between the plan and the delivery. A daily treatment delivery report is designed to include all required information for IGRT and weekly physics reviews including the plan and treatment fraction information, daily beam output information, and the treatment delivery verification results. A computer program was developed to implement the proposed procedure of the automatic delivery verification and daily report generation for an MRI guided radiation therapy system. The program was clinically commissioned. Sensitivity was measured with simulated errors. The final version has been integrated into the commercial version of the treatment delivery system. The method automatically verifies the EBRT treatment deliveries and generates the daily treatment reports. Already in clinical use f or over one year, it is useful to facilitate delivery error detection, and to expedite physician daily IGRT review and physicist weekly chart review.
A framework for automated contour quality assurance in radiation therapy including adaptive techniques.
Altman, M. B., Kavanaugh, J. A., Wooten, H. O., Green, O. L., DeWees, T. A., Gay, H., ... & Mutic, S. (2015)
Physics in medicine and biology
The article has a video abstract association, but video not found in the video repository. Contouring of targets and normal tissues is one of the largest sources of variability in radiation therapy treatment plans. Contours thus require a time intensive and error-prone quality assurance (QA) evaluation, limitations which also impair the facilitation of adaptive radiotherapy (ART). Here, an automated system for contour QA is developed using historical data (the 'knowledge base'). A pilot study was performed with a knowledge base derived from 9 contours each from 29 head-and-neck treatment plans. Size, shape, relative position, and other clinically-relevant metrics and heuristically derived rules are determined. Metrics are extracted from input patient data and compared against rules determined from the knowledge base; a computer-learning component allows metrics to evolve with more input data, including patient specific data for ART. Nine additional plans containing 42 unique contouring errors were analyzed. 40/42 errors were detected as were 9 false positives. The results of this study imply knowledge-based contour QA could potentially enhance the safety and effectiveness of RT treatment plans as well as increase the efficiency of the treatment planning process, reducing labor and the cost of therapy for patients.
Characterization of the onboard imaging unit for the first clinical magnetic resonance image guided radiation therapy system
Hu, Y., Rankine, L., Green, O. L., Kashani, R., Li, H. H., Li, H., . . . Mutic, S. (2015)
To characterize the performance of the onboard imaging unit for the first clinical magnetic resonance image guided radiation therapy (MR-IGRT) system.
The imaging performance characterization included four components: ACR (the American College of Radiology) phantom test, spatial integrity, coil signal to noise ratio (SNR) and uniformity, and magnetic field homogeneity. The ACR phantom test was performed in accordance with the ACR phantom test guidance. The spatial integrity test was evaluated using a 40.8×40.8×40.8 cm3 spatial integrity phantom. MR and computed tomography (CT) images of the phantom were acquired and co-registered. Objects were identified around the surfaces of 20 and 35 cm diameters of spherical volume (DSVs) on both the MR and CT images. Geometric distortion was quantified using deviation in object location between the MR and CT images. The coil SNR test was performed according to the national electrical manufacturers association (NEMA) standards MS-1 and MS-9. The magnetic field homogeneity test was measured using field camera and spectral peak methods.
For the ACR tests, the slice position error was less than 0.10 cm, the slice thickness error was less than 0.05 cm, the resolved high-contrast spatial resolution was 0.09 cm, the resolved low-contrast spokes were more than 25, the image intensity uniformity was above 93%, and the percentage ghosting was less than 0.22%. All were within the ACR recommended specifications. The maximum geometric distortions within the 20 and 35 cm DSVs were 0.10 and 0.18 cm for high spatial resolution three-dimensional images and 0.08 and 0.20 cm for high temporal resolution two dimensional cine images based on the distance-to-phantom-center method. The average SNR was 12.0 for the body coil, 42.9 for the combined torso coil, and 44.0 for the combined head and neck coil. Magnetic field homogeneities at gantry angles of 0◦, 30◦, 60◦, 90◦, and 120◦ were 23.55, 20.43, 18.76, 19.11, and 22.22 ppm, respectively, using the field camera method over the 45 cm DSV.
The onboard imaging unit of the first commercial MR-IGRT system meets ACR, NEMA, and vendor specifications.
Dosimetric feasibility of magnetic resonance imaging‐guided tri-cobalt 60 preoperative intensity modulated radiation therapy for soft tissue sarcomas of the extremity.
Kishan, A. U., Cao, M., Mikaeilian, A. G., Low, D. A., Kupelian, P. A., Steinberg, M. L., & Kamrava, M (2015)
Practical Radiation Oncology,
The purpose of this study was to investigate the dosimetric differences of delivering preoperative intensity modulated radiation therapy (IMRT) to patients with soft tissue sarcomas of the extremity (ESTS) with a teletherapy system equipped with 3 rotating 60Co sources and a built-in magnetic resonance imaging and with standard linear accelerator (LINAC)‐based IMRT.
Methods and materials
The primary study population consisted of 9 patients treated with preoperative radiation for ESTS between 2008 and 2014 with LINAC-based static field IMRT. LINAC plans were designed to deliver 50 Gy in 25 fractions to 95% of the planning target volume (PTV). Tri-60Co system IMRT plans were designed with ViewRay system software.
Tri-60Co‐based IMRT plans achieved equivalent target coverage and dosimetry for organs at risk (long bone, skin, and skin corridor) compared with LINAC-based IMRT plans. The maximum and minimum PTV doses, heterogeneity indices, and ratio of the dose to 50% of the volume were equivalent for both planning systems. One LINAC plan violated the maximum bone dose constraint, whereas none of the tri-60Co plans did.
Using a tri-60Co system, we were able to achieve equivalent dosimetry to the PTV and organs at risk for patients with ESTS compared with LINAC-based IMRT plans. The tri-60Co system may be advantageous over current treatment platforms by allowing PTV reduction and by elimination of the additional radiation dose associated with daily image guidance, but this needs to be evaluated prospectively.
Patient-Specific Quality Assurance for the Delivery of 60Co Intensity Modulated Radiation Therapy Subject to a 0.35-T Lateral Magnetic Field.
Li, H. H., Rodriguez, V. L., Green, O. L., Hu, Y., Kashani, R., Wooten, H. O., . . . Mutic, S. (2015)
International Journal of Radiation Oncology* Biology* Physics
This work describes a patient-specific dosimetry quality assurance (QA) program for intensity modulated radiation therapy (IMRT) using ViewRay, the first commercial magnetic resonance imaging-guided RT device.
Methods and Materials
The program consisted of: (1) a 1-dimensional multipoint ionization chamber measurement using a customized 15-cm3 cube-shaped phantom; (2) 2-dimensional (2D) radiographic film measurement using a 30-x 30-x 20-cm3 phantom with multiple inserted ionization chambers; (3) quasi-3D diode array (Arc- CHECK) measurement with a centrally inserted ionization chamber; (4) 2D fluence verification using machine delivery log files; and (5) 3D Monte Carlo (MC) dose reconstruction with machine delivery files and phantom CT.
Ionization chamber measurements agreed well with treatment planning sys- tem (TPS)-computed doses in all phantom geometries where the mean ± SD difference was 0.0% ± 1.3% (n=102; range, -3.0%-2.9%). Film measurements also showed excellent agreement with the TPS-computed 2D dose distributions where the mean passing rate using 3% relative/3 mm gamma criteria was 94.6% ± 3.4% (n=30; range, 87.4%-100%). For ArcCHECK measurements, the mean ± SD passing rate using 3% relative/3 mm gamma criteria was 98.9% ± 1.1% (n=34; range, 95.8%- 100%). 2D fluence maps with a resolution of 1x1 mm2 showed 100% passing rates for all plan deliveries (n=34). The MC reconstructed doses to the phantom agreed well with planned 3D doses where the mean passing rate using 3% absolute/3 mm gamma criteria was 99.0% ± 1.0% (n=18; range, 97.0%-100%), demonstrating the feasibility of evaluating the QA results in the patient geometry.
We developed a dosimetry program for ViewRay’s patient-specific IMRT QA. The methodology will be useful for other ViewRay users. The QA results presented here can assist the RT community to establish appropriate tolerance and action limits for ViewRay’s IMRT QA.
Comparison of onboard low-field magnetic resonance imaging versus onboard computed tomography for anatomy visualization in radiotherapy.
Noel, C. E., Parikh, P. J., Spencer, C. R., Green, O. L., Hu, Y., Mutic, S., & Olsen, J. R. (2015)
Onboard magnetic resonance imaging (OB-MRI) for daily localization and adaptive radiotherapy has been under development by several groups. However, no clinical studies have evaluated whether OB-MRI improves visualization of the target and organs at risk (OARs) compared to standard onboard computed tomography (OB-CT). This study compared visualization of patient anatomy on images acquired on the MRI-60Co ViewRay system to those acquired with OB-CT.
Material and methods
Fourteen patients enrolled on a protocol approved by the Institutional Review Board (IRB) and undergoing image-guided radiotherapy for cancer in the thorax (n=2), pelvis (n=6), abdomen (n=3) or head and neck (n=3) were imaged with OB-MRI and OB-CT. For each of the 14 patients, the OB-MRI and OB-CT datasets were displayed side-by-side and independently reviewed by three radiation oncologists. Each physician was asked to evaluate which dataset offered better visualization of the target and OARs. A quantitative contouring study was performed on two abdominal patients to assess if OB-MRI could offer improved inter-observer segmentation agreement for adaptive planning.
In total 221 OARs and 10 targets were compared for visualization on OB-MRI and OB-CT by each of the three physicians. The majority of physicians (two or more) evaluated visualization on MRI as better for 71% of structures, worse for 10% of structures, and equivalent for 14% of structures. 5% of structures were not visible on either. Physicians agreed unanimously for 74% and in majority for >99% of structures. Targets were better visualized on MRI in 4/10 cases, and never on OB-CT.
Low-field MR provides better anatomic visualization of many radiotherapy targets and most OARs as compared to OB-CT. Further studies with OB-MRI should be pursued.
Commissioning Experience of Tri-Cobalt-60 MRI-guided Radiation Therapy System.
Park, J. M., Park, S. Y., Wu, H. G., & Kim, J. I. (2015)
Progress in Medical Physics
The aim of this study is to present commissioning results of the ViewRay system. We verified safety functions of the ViewRay system. For imaging system, we acquired signal to noise ratio (SNR) and image uniformity. In addition, we checked spatial integrity of the image. Couch movement accuracy and coincidence of isocenters (radiation therapy system, imaging system and virtual isocenter) was verified. Accuracy of MLC positioning was checked. We performed reference dosimetry according to American Association of Physicists in Medicine (AAPM) Task Group 51 (TG-51) in water phantom for head 1 and 3. The deviations between measurements and calculation of percent depth dose (PDD) and output factor were evaluated. Finally, we performed gamma evaluations with a total of 8 IMRT plans as an end-to-end (E2E) test of the system. Every safety system of ViewRay operated properly. The values of SNR and Uniformity met the tolerance level. Every point within 10 cm and 17.5 cm radii about the isocenter showed deviations less than 1 mm and 2 mm, respectively. The average couch movement errors in transverse (x), longitudinal (y) and vertical (z) directions were 0.2 mm, 0.1 mm and 0.2 mm, respectively. The deviations between radiation isocenter and virtual isocenter in x, y and z directions were 0 mm, 0 mm and 0.3 mm, respectively. Those between virtual isocenter and imaging isocenter were 0.6 mm, 0.5 mm and 0.2 mm, respectively. The average MLC positioning errors were less than 0.6 mm. The deviations of output, PDDs between measured vs. BJR supplement 25, PDDs between measured and calculated and output factors of each head were less than 0.5%, 1%, 1% and 2%, respectively. For E2E test, average gamma passing rate with 3%/3 mm criterion was 99.9%±0.1%.
Characterization of a 0.35T MR system for phantom image quality stability and in vivo assessment of motion quantification.
Saenz, D. L., Yan, Y., Christensen, N., Henzler, M. A., Forrest, L. J., Bayouth, J. E., & Paliwal, B. R. (2015)
Journal of Applied Clinical Medical Physics
ViewRay is a novel MR-guided radiotherapy system capable of imaging in near real-time at four frames per second during treatment using 0.35T field strength. It allows for improved gating techniques and adaptive radiotherapy. Three cobalt-60 sources (~ 15,000 Curies) permit multiple-beam, intensity-modulated radiation therapy. The primary aim of this study is to assess the imaging stability, accuracy, and automatic segmentation algorithm capability to track motion in simulated and in vivo targets. Magnetic resonance imaging (MRI) characteristics of the system were assessed using the American College of Radiology (ACR)-recommended phantom and accreditation protocol. Images of the ACR phantom were acquired using a head coil following the ACR scanning instructions. ACR recommended T1- and T2-weighted sequences were evaluated. Nine measurements were performed over a period of seven months, on just over a monthly basis, to establish consistency. A silicon dielectric gel target was attached to the motor via a rod. 40 mm total amplitude was used with cycles of 3 to 9 s in length in a sinusoidal trajectory. Trajectories of six moving clinical targets in four canine patients were quantified and tracked. ACR phantom images were analyzed, and the results were compared with the ACR acceptance levels. Measured slice thickness accuracies were within the acceptance limits. In the 0.35 T system, the image intensity uniformity was also within the ACR acceptance limit. Over the range of cycle lengths, representing a wide range of breathing rates in patients imaged at four frames/s, excellent agreement was observed between the expected and measured target trajectories. In vivo canine targets, including the gross target volume (GTV), as well as other abdominal soft tissue structures, were visualized with inherent MR contrast, allowing for preliminary results of target tracking.