Assessing MR-linac radiotherapy robustness for anatomical changes in head and neck cancer.

The MR-Linac will provide excellent soft tissue contrast for on-treatment imaging. It is well known that the electron return effect (ERE) results in areas of increased and decreased dose at air/tissue boundaries, which can be compensated for in plan optimisation. However, anatomical changes may affect the quality of this compensation. In this paper we aim to quantify the interaction of anatomical changes with ERE in head and neck (H&N) cancer patients. Twenty patients treated with either 66 Gy or 60 Gy in 30 fractions were selected. Ten had significant weight-loss during treatment requiring repeat CT (rCT) and ten had PTVs close to the sinus cavity. Plans were optimised using Monaco to meet the departmental dose constraints and copied to the rCT and re-calculated. For the sinus patients, we optimised plans with full and empty sinus at both 0 T and 1.5 T. The effect of the opposite filling state was next evaluated. No clinically relevant difference between the doses in the PTV and OARs were observed related to weight-loss in 0 T or 1.5 T fields. Variable sinus filling caused greater dosimetric differences near the walls of the sinus for plans optimised with a full cavity in 1.5 T, indicating that optimising with an empty sinus makes the plan more robust to changes in filling. These findings indicate that current off-line strategies for adaptive planning for H&N patients are also valid on an MR-linac, if care is taken with sinus filling.