Article Reviewed:

Adjeiwaah, M., Garpebring, A., & Nyholm, T. (2020). Sensitivity analysis of different quality
assurance methods for magnetic resonance imaging in radiotherapy | Semantic Scholar.
Retrieved March 3, 2023, from https://www.semanticscholar.org/paper/Sensitivity-analysis-of-
different-quality-assurance-

In this article entitled as “Sensitivity Analysis of Different Quality Assurance Methods for
Magnetic Resonance Imaging in Radiotherapy,” Mary Adjeiwaah, Anders Garpebring, and Tufve
Nyholm from Department of Radiation Sciences in Umeå University, Sweden examined the two
QA protocols, American College of Radiology (ACR) Magnetic Resonance Imaging Quality
Assurance phantom and a commercial large field-of-view (FoV) geometric accuracy phantom to
detect common events that affect quality of MR images under routine radiotherapy setting to
identify the common issues that degrade the quality of Magnetic Resonance images. In order to
accomplish this, objective machine-specific action limits for key image quality parameters were
established and the sensitivity of the QA protocols to objectively detect the introduced image
quality degradations was then investigated.

The Comprehensive RT-Specific Quality Assurance for MRI Simulation utilized in this
research study offers RT-specific activities for daily, weekly, monthly, and yearly Quality
Assurance routines. As mentioned, American College of Radiology (ACR) and the American
Association of Physicists in Medicine (AAPM), are two international organizations that provided
reference guidance on acceptance testing, commissioning, and ongoing Quality Assurance
procedures for clinical Magnetic Resonance Imaging (MRI) scanners as there is no definite
quality assurance (QA) procedures for radiotherapy's use of magnetic resonance imaging (MRI).
Based on this research study, the geometric accuracy, high-contrast spatial resolution, slice
thickness accuracy, slice position accuracy, image intensity uniformity, percent-signal ghosting,
and low contrast object detectability are seven quantitative factors that affect the quality of MR
images. Additionally, for many RT image acquisitions, a large field-of-view (FoV) is needed to
accurately cover the tumor volume, organs at risk (OAR), and the external body contours within
the imaged region of interest, with gradient linearity and field homogeneity the inclusion of a
large field-of-view (FoV) geometric accuracy phantom in Quality Assurance procedures for MRI
in RT has been highly recommended (Sreedher, G et al., 2021).

In this study, the researchers used sensitivity analysis to assess the robustness by
determining the degree to which results are impacted by modifications to methods, models,
values of unmeasured variables, or assumptions. The American College of Radiology (ACR) MRI
Phantom is an 8" (203.2 mm) diameter cylinder, 6.82" (173.40 mm) tall with various fixtures
inside, including a grid, cylinders, and other points of interest. Marked with reference points for
nose and chin to aid in orienting the phantom for scanning. On the other hand, the commercial
geometric accuracy phantom contains 1177 spherical markers filled with polyethylene glycol
and the outer casing was 502 404×534 mm3 with a signal producing volume of 438.7×346.0×
470.0 mm3 and all images were acquired using a 3 T GE Signa PET/MR scanner that has a
stronger magnet and makes better images of organs and soft tissue than other types of MRI do.
 Based on the given data, the researchers determined that the machine-specific limits for
key image quality parameters were set as the mean ± 3σ based on repeated measurements
under routine radiotherapy settings. By setting the limits at ± 3σ, it was expected that less than
1% of all measured data points would be above the ± 3σ line. Given this data, the geometric
accuracy phantom was found to be much more sensitive to uncorrected gradient nonlinearity
effects than field inhomogeneities caused by the piece of metal. To test the reliability of results,
six scans were performed on the American College of Radiology (ACR) phantom and during each
of the two scanning sessions, the data's normal distribution was evaluated using a one-sample
Kolmogorov-Smirnov test and action limits were calculated for the following variables derived
from the images such as image uniformity, slice thickness, slice position accuracy, ghosting,
geometric accuracy, and signal-to-noise (SNR). The effects of provocation showed that the
magnetic resonance environment includes a strong, fixed magnetic field, an electromagnetic
force that changes over time (pulsed gradient field), and radiofrequency energy that can attract
magnetic objects from small items such as keys and cell phones, to large and heavy items such
as oxygen tanks and floor buffers) may cause damage to the scanner or injury to the patient and
medical professionals if those objects become projectiles. This can also make the MRI scan
uninformative or may lead to an inaccurate clinical diagnosis potentially resulting in
inappropriate medical treatment. In order to ensure that nothing enters the magnet area,
careful screening of people and objects entering the MR environment is essential in quality
assurance modifications.

At the time of this study, it was not possible to remove individual coil elements to build
a composite image on the scanner console (Lu, W et al., 2019). The use of the matrix laboratory
(MATLAB) code provided by the manufacturer to reconstruct the phantom raw data while
simulating coil element failure may have limitations in this study. In the context of the results, it
is advised that machine-specific limits for each system be identified and used as a benchmark
for constancy checks or regular Magnetic Resonance Imaging in routine Radiotherapy Quality
Assurance procedures rather than the American College of Radiology acceptance values. Aside
from this, miscalibration of one or more imaging gradients is the most common cause of
geometric errors. Gradients tend to drift over time and must be re-calibrated on a regular basis
by service engineers. Occasionally, the problem is caused by B o inhomogeneity caused by
improper shim adjustments, or an occult ferromagnetic object lodged in the scanner bore.
Based on the seven quantitative measures, when the Magnetic Resonance images are
inherently distorted, the magnitude of these distortions increases as the radial distance from
the scanner's isocenter increases, because of this the ACR phantom with its 190 mm diameter,
may not be the best tool for characterizing distortions and MRI scanners that have typically a
diameter of around 600 mm is much better. Furthermore, measuring geometric accuracy on
two slices within a defined volume of 105 mm posed obvious limitations.

In conclusion, MRI is transforming the radiotherapy planning process, patients are not
exposed to the negative effects of ionizing radiation because MR images are created without
the use of any ionizing radiation. Clinical magnetic resonance imaging (MRI) scanners are crucial
for the management of patient care and the diagnosis of diseases. To get the best results from a
clinical MRI scanner in a hospital, quality assurance (QA) is required. Compared to CT, MRI offers
better soft tissue contrast and can distinguish between fat, water, muscle, and other soft tissue
(CT is usually better at imaging bones). These images give doctors knowledge and can aid in the
diagnosis of a wide range of illnesses and conditions. The two protocols, ACR MRI QA phantom
combined with the large field-of-view, with the shift to MR-only treatment planning,
commercial geometric accuracy phantom can provide comprehensive quality assurance
programs will be required to protect against machine and human performance failures while
maintaining the high levels of accuracy required for radiation therapy.

References:

Lu, W., Dong, K., Cui, D., Jiao, Q., & Qiu, J. (2019). Quality assurance of human functional
magnetic resonance imaging: a literature review. Quantitative imaging in medicine and
surgery, 9(6), 1147.

Sreedher, G., Ho, M. L., Smith, M., Udayasankar, U. K., Risacher, S., Rapalino, O., ... & Gee, M. S.
(2021). Magnetic resonance imaging quality control, quality assurance and quality
improvement. Pediatric Radiology, 51, 698-708.