Safety and Tolerability of Online Adaptive High-Field Magnetic Resonance–Guided Radiotherapy
Authors: Westerhoff Jasmijn M. , Daamen Lois A. , Christodouleas John P. , Blezer Erwin L. A. , Choudhury Ananya , Westley Rosalyne L. , Erickson Beth A. , Fuller Clifton D. , Hafeez Shaista , van der Heide Uulke A. , Intven Martijn P. W. , Kirby Anna M. , Lalondrelle Susan , Minsky Bruce D. , Mook Stella , Nowee Marlies E. , Marijnen Corrie A. M. , Orrling Kristina M. , Sahgal Arjun , Schultz Christopher J. , Faivre-Finn Corinne , Tersteeg Robbert J. H. A. , Tree Alison C. , Tseng Chia-Lin , Schytte Tine , Silk Dustin M. , Eggert Dave , Luzzara Marco , van der Voort van Zyp Jochem R. N. , Verkooijen Helena M. , Hall William A. 
Published: May 2024

ImportanceIn 2018, the first online adaptive magnetic resonance (MR)-guided radiotherapy (MRgRT) system using a 1.5-T MR–equipped linear accelerator (1.5-T MR-Linac) was clinically introduced. This system enables online adaptive radiotherapy, in which the radiation plan is adapted to size and shape changes of targets at each treatment session based on daily MR-visualized anatomy.ObjectiveTo evaluate safety, tolerability, and technical feasibility of treatment with a 1.5-T MR-Linac, specifically focusing on the subset of patients treated with an online adaptive strategy (ie, the adapt-to-shape [ATS] approach).Design, Setting, and ParticipantsThis cohort study included adults with solid tumors treated with a 1.5-T MR-Linac enrolled in Multi Outcome Evaluation for Radiation Therapy Using the MR-Linac (MOMENTUM), a large prospective international study of MRgRT between February 2019 and October 2021. Included were adults with solid tumors treated with a 1.5-T MR-Linac. Data were collected in Canada, Denmark, The Netherlands, United Kingdom, and the US. Data were analyzed in August 2023.ExposureAll patients underwent MRgRT using a 1.5-T MR-Linac. Radiation prescriptions were consistent with institutional standards of care.Main Outcomes and MeasuresPatterns of care, tolerability, and technical feasibility (ie, treatment completed as planned). Acute high-grade radiotherapy-related toxic effects (ie, grade 3 or higher toxic effects according to Common Terminology Criteria for Adverse Events version 5.0) occurring within the first 3 months after treatment delivery.ResultsIn total, 1793 treatment courses (1772 patients) were included (median patient age, 69 years [range, 22-91 years]; 1384 male [77.2%]). Among 41 different treatment sites, common sites were prostate (745 [41.6%]), metastatic lymph nodes (233 [13.0%]), and brain (189 [10.5%]). ATS was used in 1050 courses (58.6%). MRgRT was completed as planned in 1720 treatment courses (95.9%). Patient withdrawal caused 5 patients (0.3%) to discontinue treatment. The incidence of radiotherapy-related grade 3 toxic effects was 1.4% (95% CI, 0.9%-2.0%) in the entire cohort and 0.4% (95% CI, 0.1%-1.0%) in the subset of patients treated with ATS. There were no radiotherapy-related grade 4 or 5 toxic effects.Conclusions and RelevanceIn this cohort study of patients treated on a 1.5-T MR-Linac, radiotherapy was safe and well tolerated. Online adaptation of the radiation plan at each treatment session to account for anatomic variations was associated with a low risk of acute grade 3 toxic effects.