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Trade Magazine Analysis

The article “Real-time Radiotherapy” published in Radiology Today discusses the new

MRI linear accelerator to be released in the United States, awaiting the promising approval for

clinical applications by the FDA. The article discusses the historical relevance of MR imaging in

radiation oncology and its implications in creating a “personalized therapy” for patients with its

incorporation into a linear accelerator.1 The idea is that targeted therapy can be accomplished by

being able to better differentiate between tissue densities of critical structures and tumor volumes

using MRI imaging. Further maximizing this benefit, is the ability for the programming of the

MRI linear accelerator to allow for real-time dosimetric changes to be made to treatment plans at

the time of treatment delivery based off imaging. While there are several great features to this

article and its relevance to the field, there are many differences that make it a less reliable source

than a peer-reviewed piece.

This article does a great job at introducing valuable new technology that is emerging in

the field of radiation oncology. If this MRI linear accelerator really does improve the efficacy of

delineating treatment volumes and tracking treatment response, then it could significantly impact

the future of the field. The idea for adaptive planning has been around for a very long time,

however the technology to effectively and efficiently implement it has been lacking. The

possibility of re-planning a case minutes before treatment delivery would place such a high

demand on medical dosimetrists and physicians. Their collaboration and expertise would be

needed for each fraction being delivered at the machine. The technology described in the article

seems impressive and in the best interest of the patient, however it would change the whole

dynamic of the treatment team.

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This article also does a good job of holding the interest of the audience. This article

stylistically resembles a news report; the layout of the article is easy to follow, and any advanced

terminology is thoroughly explained. Also, the information throughout the article is supported

with many quotations from “experts” in the field. However, upon further dissection, there are

some questionable points to consider when determining the reliability of the source. One

consideration is the author’s background. There is a notation that the author is a freelance

medical writer, however there is no indication that the author is a member in the actual field of

radiation oncology. Another consideration is who the author chooses as her “experts” to support

the information provided in the article. Most of the quotations are made by affiliates of the MRI

linear accelerator companies, Elekta and ViewRay, allowing some potential for bias when trying

to market a new product. Finally, there are no references or citations in the article that provide

evidence of research. The key details in the article are supported with opinions rather than

scientific proof.

Overall, this article did a great job summarizing an exciting new technology coming soon

to radiation oncology. As a reader, it created more of an emotional response than provoking a

deeper analysis of the information presented. The article’s purpose seemed to promote an interest

in new technology for readers to pursue further. However, because of lacking pertinent research

and questionable reliability of sources, this article would not be advisable to use as scientific

evidence.
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References:

1. Orenstein BW. Real-Time Radiotherapy. Radiology Today.

http://www.radiologytoday.net/archive/rt0117p16.shtml. Published January 2017.

Accessed January 26, 2018.

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Journal Article Analysis

The article “Towards Fast Online Intrafraction Re-planning for Free-breathing

Stereotactic Body Radiation Therapy with the MRI-linac” by C Kontaxis et al, describes the

treatment adaptation process used for three test patients with Renal Cell Carcinoma (RCC). The

article describes the how MR imaging obtained during treatment can be used with the MR Linac

Treatment Planning software (MRLTP) by performing 3D anatomical deformations to account

for changes in anatomy and motion during treatment. The analysis of this article will delve into

the details of the research carried out, results and conclusion, and how this article is notable as a

peer reviewed source.

The author begins the article with an introduction and describes the purpose of the

research. The current treatment methods of using external beam radiation therapy for Stereotactic

Body Radiation Therapy (SBRT) are described with an emphasis on the struggles of creating

adequate treatment volumes to account for motion when trying to spare normal tissues. The

author then introduces the MR-linac which will allow for physicians to see real-time motion

during treatment delivery. The proposal for this research is to determine the “feasibility of a

novel adaptive free-breathing SBRT treatment for RCC based on 3D anatomical deformations

pre-calculated from high frequency MRI motion data.”1 Objectives such as target coverage and

normal tissue sparing will be assessed as a measure of system performance.

The research carried out in this article was of a significantly small population, mostly due

to the new release of the MRI linear accelerator. The sample size is only comprised of three

patients all treated for RCC with SBRT. The treatment methods are described thoroughly with

diagrams of all steps performed throughout the adaptive process. The process begins with

pretreatment imaging of the patient to determine baseline motion data and reference volumes.
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Then the patient undergoes online imaging with the delivery of the first treatment beam, which is

then compared to the reference to create a 3D anatomic deformation of changes in the patient. At

this time, re-planning occurs with dose information accounted for from the delivery of the first

beam, and subsequent beams are altered to reflect anatomical changes. The figure below is an

example of the intricate mapping and utilization of both pretreatment and online imaging

information to perform intrafraction re-planning.

Figure 1. Procedural mapping of the Intrafraction Re-planning Process1

The results of the study were determined by comparing a static, or motionless treatment

plan to the adaptive treatment plan. The mean treatment delivery times differed by 2.8 minutes of

which was spent on intrafraction re-planning. All three patients displayed an increase in higher

GTV coverage and a higher mean GTV dose with the adaptive plan. The adaptive planning

process was also able to spare normal tissue dose by conforming more to the target volume.

Specific organs at risk were analyzed including the ipsilateral kidney, which was found to

decrease on average by 22.9% in dose.1 The results were adequately explained to show how the

findings were obtained and compared. Finally, the article concludes with the determination that
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the intrafraction re-planning process can be applied to treatment sites affected by motion. The

benefits of the treatment adaptation process are supported by the results of better target volume

coverage, and increased sparing of normal tissue dose.

Overall, I think that the procedure and initial findings in this research supports the

author’s conclusion. One improvement to the study is that there may need to be more patients

enrolled to increase credibility, since only three patients were analyzed. However, this

technology is very new, so perhaps once more resources are available a larger study can be

completed. In comparison to the trade magazine article, this research is supported with a clear

method of how data was obtained. Also, the peer reviewed article contains a discussion section

in which the research is critiqued for other variables that may not have been considered, and

acknowledgements are made which discloses a partnership with Elekta. The author is very

forthcoming with any deficits or bias in research, whereas the trade article masked some of these

relationships. In summary, the peer reviewed article has much more useful information that I

would feel confident citing as a source.

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References:

1. Kontaxis C, Bol GH, Stemkens B, et al. Towards fast online intrafraction replanning for

free-breathing stereotactic body radiation therapy with the MR-linac. Physics in Medicine

& Biology. 2017;62(18):7233-7248. doi:10.1088/1361-6560/aa82ae.