Article Comparison: Trade Publication Article Vs Peer review Article

Peter S Metuge
Part I: Trade Publications
Trade publications are professional publications meant to target a broad audience
usually people of that profession, are informal and are also informational; however, they
are not necessarily peer-reviewed.1 Usually they have an advisory panel with subject
matter experts, editors, and they seek out people in the profession to write most of the
articles.2 In this article review, I will be reviewing an article from the Radiology Today
Magazine called MRI-Guided Radiation Therapy written by Kathy Hardy and will be
exploring whether this article is helpful to practicing Dosimetrist, the accuracy of the
information provided by the author and the finally the strengths and the weaknesses of
the article.
One of the fast developing areas in the field of Radiation Oncology and of particular
interest in dosimetry is adaptive radiotherapy. Adaptive Radiotherapy is defined as the
changing of the radiation plan delivered to a patient during the course of Radiotherapy to
account for changes in anatomy due to weight loss or tumor shrinkage. Adaptive
radiotherapy requires that a new plan be made for the patient and can occur at three
different time scales.3 This article discusses about a new technology developed by View
Ray called MRIdian. It involves integrating real time Magnetic Resonance Imaging
(MRI) in Radiation therapy (RT) which provides better information to the physician to
determine whether a new plan is needed or not. MRI provides a superior contrast as far as
soft tissue is concerned and integrating it in RT will not only help enhance the treatment
planning process but also reduce the complications rate of patients and spare normal
surrounding tissue. I found this article very helpful and very informative. One of the draw
backs we have in the localization and delivery of Radiation dose is Ionizing radiation. For
daily localizations, most centers utilize Cone Beam CT (CBCT) or KV matching which is
excellent to visualize bony anatomy but can be challenging to see soft tissue. Both
localization methods use Ionizing radiation hence increased the patients chance of a
secondary cancer. With the MRIdian system, MRI guidance can provide image guidance
both before and concurrently with treatment with no fear of exposing the patient to

additional ionizing radiation.2This will be very helpful to practicing Dosimetrists as well

as student Dosimetrists as the intended goals of the plans we generate will be achieved i.e
to minimize dose to critical and normal tissues. We have always be thought of ALARA
(As low as reasonably achievable); this system will help us greatly achieve that. Also,
when tumor volumes shrink or a patient loses weight, a new plan can be quickly
generated to spare normal tissue.
Some of the strengths of the article will be the minimizing of ionizing radiation to
patients by using the MRIdian system. MRI does not produce Ionizing radiation hence
the chance of secondary cancer will be minimized. Also, it well know that MRI provides
a superior soft tissue contrast than CT hence more tissue sparing can be achieved with
this system than with the current system of CBCT or KV matching. One of the
weaknesses of the article is that the MRIdian system is not compatible with external
beam radiation system because of the interference of the Radiofrequency with the MRI
signal. This means majority of centers in the United States will not be able to utilize this
technology except they are willing to acquire a cobalt unit. Furthermore, the fact that
reimbursement is an issue will not make this system marketable to Cancer Centers.
In conclusion, it was a great article and a very informative. I hope with continuous
research and development, ViewRay will find a way to incorporate this system into
current external beam radiation systems and lobby hard for reimbursement for usage of
this system to provide care for Cancer patients.

1. Lenards N, Weege M. Radiation Therapy and Medical Dosimetry Reading.

[PowerPoint]. La Crosse, WI UW-L Medical Dosimetry Program; 2012
2. Kathy Hardy (September 2014) MRI-Guided Radiation Therapy. Radiology Today,
Accessed 3/22/2015. http://www.radiologytoday.net/archive/rt0914p20.shtml
3. Lei Dong (September 13-14 2012) American Association of Medical Dosimetrist
Region II Meeting. What do you know about Adaptive Radiotherapy [PowerPoint]
Accessed 3/24/2015. http://www.medicaldosimetry.org/pub/39813d43-2354-d714516b-e51adf7656b4

September 2014
MRI-Guided Radiation Therapy
By Kathy Hardy
Radiology Today
Vol. 15 No. 9 P. 20
Precise adaptive radiation therapy guided by real-time MRI images could prove a
significant advance in radiation oncology. Integrating those two tools is the driving force
behind the MRIdian system, a combined real-time MRI and radiation therapy delivery
process developed by Cleveland-based ViewRay. The system received 510(k) clearance
in 2012 and is now in use in several locations, including the Siteman Cancer Center at
Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis,
where the first system was installed and patients first underwent radiation therapy in
January 2014. Similar in concept to the Accuray Tomotherapy System that integrates CT
imaging and radiation therapy, the MRIdian system integrates MR imaging and radiation
therapy. MRI guidance can provide image-guidance both before therapy and also
concurrent with treatment without exposing the patient to the additional ionizing
radiation of CT scans. Physicians using the system say it gives them a real-time view of
whats happening in a patients body at the time of each treatment, taking advantage of
MRIs strength in imaging soft tissue. On-board imaging at the time of treatment enables
adjustment of the targeted radiation treatments, minimizing the possibility of damaging
healthy organs located near a tumor. MRI-guided imaging improves the localization for
delivery of radiation dose to the target vs the surrounding tissue, says Jeffrey R. Olsen,
MD, an assistant professor of radiation oncology at Barnes-Jewish Hospital and
Washington University School of Medicine. From a patient perspective, the treatment
experience is similar to standard radiation treatment delivered with a linear accelerator.
The difference compared to current standard treatments with the MRIdian system is the
soft tissue imaging. Current standards of localization using a technology called cone
beam CT are good for bone visualization but more challenging for soft tissue
localization. In addition to targeting, the system offers physicians an assessment of

whether the tumor has reduced or grown in size before each treatment. With real-time
MRI images we can see what were dealing with over the course of the patients
treatment, says Clifford G. Robinson, MD, an assistant professor of radiation oncology
at Barnes-Jewish Hospital and Washington University School of Medicine. You can see
changes in the soft tissue and then modify the treatment to adjust for those changes. This
is an important point with this technology. It allows you to see shifts in the tumor over
time, with real-time MRI imaging. The 510(k) clearance permits the system to be used
with radiation therapy in any part of the body where other forms of radiation therapy are
prescribed, according to Michael Saracen, senior director of marketing for ViewRay. He
says one of the first treatments delivered by the MRIdian system was stereotactic body
radiation therapy for lung cancer. In this instance, high radiation doses were delivered to
small, well-defined tumors to kill cancer cells while minimizing exposure to surrounding
healthy organs. While approval is broad with its 510(k) substantial equivalency clearance,
radiation oncologists are still investigating the systems potential uses. This is a novel
system, and we have no precedent for its use, Robinson says. Were still identifying
who would benefit from this system. When we see someone in consultation now that we
would have previously used a CT scan for imaging guidance, we now think about their
compatibility with MRI coils and whether theyre a candidate for this technology.
Robinsons focus at the Siteman Center is on patients with brain and lung tumors. Before
each treatment, he obtains changes in tumor volume and position in real time using the
scanner. Patients are screened the same way they would be if the physicians were
considering an MRI for other purposes, he says. Patients undergo low-resolution scans to
verify positioning followed by high-resolution scans to see the needed views of where the
tumor is located, he says. Soft Tissue Imaging For soft tissue, the view is out of this
world, Robinson says. Being able to track tumor movement is not novel in and of itself.
But I would have used fiducial markers in the past. In this case, the tumor is the fiducial.
Cancers are highly dynamic systems that can undergo significant changes over the
treatment course. In general, cancer treatment therapy is administered according to a
fixed, linear protocol. However, as the concept of personalized medicine spreads into
practice, the idea of managing a patients treatment based on his or her individual
characteristics instead of a standard of care determined by outcomes in a larger patient

group is gaining more attention. Thats where users of this MRI-guided system see the
real-time view playing a valuable role in individualizing a course of treatment that best
suits their patients needs. By using MRI at the time of treatment, physicians now have
the ability to process the image and calibrate the radiation dose, providing adaptive
therapy, Saracen says. MRI takes into consideration changes in anatomy that could be
caused by things like a full bladder or tumor size changes. Youre not treating to a plan
that was created last week. For Olsen, soft tissue imaging is at the core of his practice.
At the Siteman Center, his focus is in the abdominal region, treating patients with
gastrointestinal, musculoskeletal, colorectal, esophageal, and pancreatic cancers. He says
these areas of the body are also where physicians see a high degree of tumor motion and
some of the greatest areas of change. The same is true for the lungs and surrounding areas
where respiratory motion can complicate treatment. Managing Motion Its difficult to
see specific anatomic changes during treatment with current imaging modalities, Olsen
says. There is a lot of motion in those areas. MRI enables you to see variability and if
you can see that, you can potentially adapt the treatment plan. Current treatment
planning systems allow generation of precise radiation treatment plans, he adds. What
has lagged behind, however, is technology to confirm patient positioning at the same
level of accuracy, and to evaluate changes in anatomy during treatment. MRI allows
improved visualization of soft tissue anatomic change, where we previously had to rely
on fiducial markers. Olsen also points to visibility issues in the head, neck, cervical area,
and spine, where the use of MRI guidance can help overcome a different problem. While
there are fewer motion issues in head and neck cancers, treatment is often in close
proximity to sensitive neurological structures. Tumors can adapt to neurological
structures such as optic nerves, which are also difficult to visualize with current forms of
localization imaging, Olsen says. According to Saracen, radiation is used as a treatment
method with approximately two-thirds of all cancer patients. During the past several
years, he says, radiation has taken on a more curative role, used in conjunction with
surgery. Image-guided radiation treatments, such as Gamma Knife, CyberKnife, and
other external beam radiation treatment tools, have come a long way but there is still the
issue of locating the exact marker placement, he says. Before the MRIdian system, there
was no way to know exactly where the tumor was located while the [radiation] beam was

on, he says. Now you can see where to place the beam in real time. With continuous
soft tissue imaging, radiation oncologists can see the tumor, monitor where the radiation
dose is being delivered, and adapt to changes in the patients anatomy. Using MRIguided treatments also reduces additional radiation exposure from CT scans, Saracen
says, because a standard radiation treatment course can require numerous additional CT
scans. While MRI-guided imaging is a tool to assist physicians in using radiation therapy
to treat patients with cancer, many find that this form of imaging is helping patients in
other ways as well. The first patient was able to see his movie, and he could see what
happened during the procedure, Saracen says. That gave him the confidence that his
cancer was being treated. Cobalt Radiation When considering MRI as a guidance tool,
Saracen says a major factor was finding a source of radiation delivery that is most
compatible with that imaging modality. External beam radiation systems emit a lot of
radiofrequency (RF) energy, which create a certain level of noise that interferes with
MR signals. When looking at radiation delivery methods to combine with MRI, we
needed to eliminate certain things that would increase the noise interference, Saracen
says. It would be like trying to listen to crickets at a rock concert. As a result, ViewRay
developers decided to go with cobalt as a radiation source instead of linear accelerators,
he says. Cobalt emits no RF energy so it doesnt interfere with the MRI system, he
says. While traditionally cobalt is not as penetrating as other sources of radiation, the
MRIdian system takes that into consideration by using highly activated cobalt, thus
pushing it into the realm of linear accelerators. In addition, the magnet itself can cause
some interference with the radiation beam, Saracen says. The stronger the magnetic
fields, the greater the effect on the electrons. However, utilizing a lower field-strength
magnet reduces the effect without diminishing the quality of the image guidance. Youre
imaging for tracking and treating the disease in real time, he says. This isnt being used
for diagnostic purposes. While ViewRay designed the MRI machine used in the system,
it uses Siemens underlying control systems, according to Saracen. The treatment
planning system using a custom designed Monte Carlo algorithm and the software that
runs the device were written by ViewRay. This integrated system allows changes to be
made on the fly, he says. Appropriate Coding As with any new technology,
reimbursement is an issue. There are two aspects to image-guided radiation therapy:

imaging for alignment purposes and delivery of the radiation treatment. For now, those
using the system say these aspects of the process are being billed separately. However,
Saracen says ViewRay customers have formed a reimbursement consortium that will start
looking at new and existing codes for the system as a whole. This latest evolution of
image-guided radiation therapy brings the possibility of more real-time benefits,
Robinson says, and could be a precursor to more adaptive planning in radiation therapy.
Im anxious to see how this will allow us to adapt the treatment plan in real time, he
says. That was never possible before. Olsen agrees, noting that trials are currently
under way that could further demonstrate how MRI-guided radiation therapy may result
in more patient-specific treatment, possibly with increased doses more closely focused on
specific targets, with improved outcomes. Going forward, we need to demonstrate
value, Olsen says. We are excited regarding this new technology, but plan to be
methodical in our evaluation, recording patient outcomes to show that were making a
difference.
Kathy Hardy is a freelance writer based in Phoenixville, Pennsylvania. - See more at:
http://www.radiologytoday.net/archive/rt0914p20.shtml#sthash.i3nVdds9.dpuf