Evaluation of plan quality in radiotherapy planning with an MR-linac

BACKGROUND & PURPOSE: Clinical introduction of magnetic resonance (MR)-guided radiotherapy involves treatment planning while taking into account machine-specific characteristics. Our aim was to investigate the feasibility of high-quality MR-linac treatment planning for an MR-linac and to benchmark MR-linac plan quality (IMRT) against current clinical practice (VMAT). MATERIALS & METHODS: Data of eight rectal and eight prostate cancer patients, who received radiotherapy on a conventional CBCT-integrated linac, were selected. Clinically acquired CTs and associated delineations of target volumes and organs-at-risk (OARs) were used for MR-linac treatment planning in Monaco. To investigate treatment planning software bias ‘quasi MR-linac plans’ were generated in Pinnacle(3) by mimicking MR-linac specific beam characteristics. MR-linac, quasi MR-linac, and clinical plans were compared and differences in target and OAR doses assessed. Differences in plan complexity were determined by the number of segments and monitor units. RESULTS: Compared to clinical plans, MR-linac plans showed a statistically significant decrease in plan homogeneity, an increase in PTV D(mean) (prostate: 0.6 Gy; rectum: 0.8 Gy) and D(1%) (prostate: 1.9 Gy; rectum: 2.0 Gy), and increases in OAR dose. Quasi MR-linac plans were comparable to MR-linac plans with respect to OAR dose and plan homogeneity. For rectal cancer an increase was seen in PTV D(mean) (0.12 Gy) and D(1%) (0.5 Gy) compared to regular MR-linac plans. All created plans were clinically equivalent to current clinical practice. CONCLUSIONS: This study demonstrates the feasibility of creating high-quality MR-linac treatment plans. The results supported the clinical introduction of an MR-linac.