Over the past decade, the application of magnetic resonance imaging (MRI) has increased, and there is growing evidence to suggest that improvements in the accuracy of target delineation in MRI-guided radiation therapy may improve clinical outcomes in a variety of cancer types. However, some considerations should be recognized including patient motion during image acquisition and geometric accuracy of images. Moreover, MR-compatible immobilization devices need to be used when acquiring images in the treatment position while minimizing patient motion during the scan time. Finally, synthetic CT images (i.e. electron density maps) and digitally reconstructed radiograph images should be generated from MRI images for dose calculation and image guidance prior to treatment. A short review of the concepts and techniques that have been developed for implementation of MRI-only workflows in radiation therapy is provided in this document.

The availability of cone beam computerized tomography (CBCT) images at the time of treatment has opened possibilities for dose calculations representing the delivered dose for adaptive radiation therapy. A significant component in the accuracy of dose calculation is the calibration of the Hounsfield unit (HU) number to electron density (ED). The aim of this work is to assess the impact of HU to ED calibration phantom insert composition and phantom volume on dose calculation accuracy for CBCT. CBCT HU to ED calibration curves for different commercial phantoms were measured and compared. The effect of the scattering volume of the phantom on the HU to ED calibration was examined as a function of phantom length and radial diameter. The resulting calibration curves were used at the treatment planning system to calculate doses for geometrically simple phantoms and a pelvic anatomical phantom to compare against measured doses. Three-dimensional dose distributions for the pelvis phantom were calculated using the HU to ED curves and compared using Chi comparisons. The HU to ED calibration curves for the commercial phantoms diverge at densities greater than that of water, depending on the elemental composition of the phantom insert. The effect of adding scatter material longitudinally, increasing the phantom length from 5 cm to 26 cm, was found to be up to 260 HU numbers for the high-density insert. The change in the HU value, by increasing the diameter of the phantom from 18 to 40 cm, was found to be up to 1200 HU for the high-density insert. The effect of phantom diameter on the HU to ED curve can lead to dose differences for 6 MV and 18 MV x-rays under bone inhomogeneities of up to 20% in extreme cases. These results show significant dosimetric differences when using a calibration phantom with materials which are not tissue equivalent. More importantly, the amount of scattering material used with the HU to ED calibration phantom has a significant effect on the dosimetric accuracy, particularly in the radial direction.