title: A 1.5 T transverse magnetic field in radiotherapy of rectal cancer: Impact on the dose distribution.
abstract: OBJECTIVE
  MRI guidance during radiotherapy has the potential to enable more accurate dose delivery, optimizing the balance between local control and treatment related toxicity. However, the presence of a permanent magnetic field influences the dose delivery, especially around air cavities. Here, electrons are able to return to the surface through which they entered the air cavity (electron return effect, ERE) locally resulting in dose hot- and cold-spots. Where RT of rectal cancer patients might benefit from MRI guidance for margin reduction, air cavities in and around the target volume are frequently present. The purpose of this research is to evaluate the impact of the presence of a 1.5 T transverse magnetic field on dose delivery in patients with rectal cancer.
  
  
  METHODS
  Ten patients treated with 5 × 5 Gy RT having large changes in pelvic air content were selected out of a cohort of 33 patients. On the planning CT, a 1.5 T, 6 MV, 7-field intensity modulated radiotherapy (IMRT) plan was created. This plan was subsequently recalculated on daily CT scans. For each daily CT, the CTV V95% and V107% and bowel area V(5Gy), V(10Gy), V(15Gy), V(20Gy), and V(25Gy) were calculated to evaluate the changes in dose distribution from fraction to fraction. For comparison, the authors repeated this procedure for the 0 T situation. To study the effect of changing air cavities separate from other anatomical changes, the authors also generated artificial air cavities in the CTV of one patient (2 and 5 cm diameter), in the high dose gradient region (2 cm), and in the low dose area (2 cm). Treatment plans were optimized without and with each simulated air cavity. For appearing and disappearing air cavities, the CTV V95% and V107% were evaluated. The authors also evaluated the ERE separate from attenuation changes locally around appearing gas pockets.
  
  
  RESULTS
  For the ten patients, at 1.5 T, the V95% was influenced by both appearing and disappearing air, and dropped to <98% in 2 out of 50 fractions due a disappearing air cavity of 150 cm(3). V95% differences between 0 and 1.5 T were all within 2%. The V107% was below 1% in 46 out of 50 fractions, and increased to 3% in the remaining fractions due to appearing air of around 120 cm(3). For comparison, V107% was <1% at 0 T for all fractions. In the bowel area, the V15Gy varied strongest from fraction to fraction, but differences between 1.5 and 0 T were minimal with an average difference of 2.3 cm(3) (SD = 18.7 cm(3), p = 0.38). For the simulated air cavities, the ERE resulted in cold-spots maximally 5% lower than prescribed and hot-spots maximally 6% higher than prescribed.
  
  
  CONCLUSIONS
  The presence of a 1.5 T magnetic field has an impact on the dose distribution when the air content changes of within a few percent in these selected rectal cancer patients. The authors consider this influence of the transverse magnetic field on the dose distribution in IMRT for rectal cancer patients clinically acceptable.
authors.affiliation: Department of Radiotherapy, NKI-AVL, Amsterdam 1066 CX, Netherlands.
authors.forename: Sander
authors.initials: S
authors.lastname: Uilkema
authors.affiliation: Department of Radiotherapy, NKI-AVL, Amsterdam 1066 CX, Netherlands.
authors.forename: Uulke
authors.initials: U
authors.lastname: van der Heide
authors.affiliation: Department of Radiotherapy, NKI-AVL, Amsterdam 1066 CX, Netherlands.
authors.forename: Jan-Jakob
authors.initials: JJ
authors.lastname: Sonke
authors.affiliation: RTP Research Group, Elekta, Maryland Heights, Missouri 63043.
authors.forename: Michel
authors.initials: M
authors.lastname: Moreau
authors.affiliation: Department of Radiotherapy, NKI-AVL, Amsterdam 1066 CX, Netherlands.
authors.forename: Baukelien
authors.initials: B
authors.lastname: van Triest
authors.affiliation: Department of Radiotherapy, NKI-AVL, Amsterdam 1066 CX, Netherlands.
authors.forename: Jasper
authors.initials: J
authors.lastname: Nijkamp
mesh_terms: D000388:Air; D015331:Cohort Studies; D003198:Computer Simulation; D008279:Magnetic Resonance Imaging / Q000295:instrumentation / Q000379:methods*; D008954:Models, Biological; D010388:Pelvis; D011874:Radiometry / Q000379:methods; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000295:instrumentation / Q000379:methods*; D061089:Radiotherapy, Image-Guided / Q000295:instrumentation / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000295:instrumentation / Q000379:methods*; D012004:Rectal Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy*; D012007:Rectum / Q000000981:diagnostic imaging / Q000473:pathology / Q000528:radiation effects; D014057:Tomography, X-Ray Computed