Development and Implementation of an MRI-Only Simulation, Planning, and Treatment Workflow for Prostate Radiotherapy Using Synthetic CT on MR-Linac.

Authors

Reza Reiazi
Yao Ding
Sarath Vijayan
Jinzhong Yang
Ergys Subashi
Yao Zhao
Belinda M Lee
Hunter L Emory
Vi T Dinh
Greg L Swiedom
Jie Deng
Mu-Han Lin
Peter Balter
Rajat J Kudchadker
Elaine E Cha
Seungtaek Choi
Yusung Kim
Eun Young Han
Surendra Prajapati

Language

English

Publication Date

2-1-2026

Journal

Journal of Applied Clinical Medical Physics

DOI

10.1002/acm2.70499

PMID

41663318

PubMedCentral® Posted Date

2-9-2026

PubMedCentral® Full Text Version

Post-print

Abstract

Purpose: We evaluated the feasibility of a magnetic resonance (MR)-only simulation, planning, and treatment (MROSPT) workflow for prostate cancer patients using synthetic computed tomography (sCT) generated from magnetic resonance imaging (MRI) data. By validating sCT-based dose calculations, we aimed to streamline radiotherapy workflows, eliminate the need for CT simulation, and enable reliable clinical implementation of MR-based radiotherapy for MR-linac (MRL).

Methods: We developed a comprehensive workflow encompassing the entire process from initial consultation to treatment delivery. After developing the workflow, a retrospective dosimetric validation study was performed on nine men with prostate cancer. They underwent CT and MRI simulations, and sCTs were generated from the MRI data. Contours and intensity-modulated radiation therapy treatment plans were created on the reference simulation CT (rCT) and transferred to sCTs for dose-calculation comparisons. Dosimetric accuracy was evaluated using gamma analysis (dose/distance; 2%/2mm). Bulk density sCTs (bCTs) were created by overriding organ density values with their mean (bulk) sCT-determined densities. bCT based on sCT allows treatment planning directly on MRI for MRL workflow efficiency.

Results: Minimal non-bone Hounsfield units (HU)-value differences between rCT and sCT (5.5 ± 2.9 HU for prostate) demonstrated the reliability of the sCT generation process. Dosimetric comparisons between treatment plans (rCT vs. sCT, rCT vs. bCT) showed agreement within ± 2% in gamma analysis, confirming robust accuracy. The gamma index pass rate for rCT versus sCT and rCT versus bCT were consistently > 95% using 2%/2 mm criteria. A dry run of the entire simulation-to-treatment workflow was successfully completed.

Conclusion: The MROSPT workflow using sCT is clinically feasible and dosimetrically accurate for prostate cancer patients. Dose calculations based on sCT demonstrated high dosimetric agreement with simulation CT, with no statistically significant differences across all evaluated metrics. These findings support the adoption of sCT‑based planning for prostate cancer radiotherapy and suggest its potential applicability in other anatomical regions especially in the pelvis. Integration of robust quality‑assurance processes and treatment‑delivery flexibility will further enhance its clinical utility.

Keywords

Humans, Male, Prostatic Neoplasms, Radiotherapy Planning, Computer-Assisted, Radiotherapy Dosage, Radiotherapy, Intensity-Modulated, Magnetic Resonance Imaging, Tomography, X-Ray Computed, Workflow, Retrospective Studies, Particle Accelerators, Organs at Risk, Computer Simulation, Image Processing, Computer-Assisted, MR‐only simulation, prostate, radiotherapy, synthetic CT

Published Open-Access

yes

Recommended Citation

Reiazi, Reza; Ding, Yao; Vijayan, Sarath; et al., "Development and Implementation of an MRI-Only Simulation, Planning, and Treatment Workflow for Prostate Radiotherapy Using Synthetic CT on MR-Linac." (2026). Faculty, Staff and Student Publications. 5333.
https://digitalcommons.library.tmc.edu/uthgsbs_docs/5333