Does the presence of Magtrace preclude adaptive breast radiotherapy on an MR-Linac?

Introduction: This work reports on an unusual finding observed during image quality assessment in the preparation for the clinical implementation of breast magnetic resonance image-guided radiotherapy (MRIgRT) on a 1.5 Tesla (T) magnetic resonance linear accelerator (MR-Linac) (Elekta AB, Stockholm, Sweden).

Case and outcomes: A patient with T2 N0 M0 right breast invasive ductal carcinoma, receiving adjuvant radiotherapy, underwent two imaging sessions on the MR-Linac. The imaging protocol included T1- and T2-weighted (W) turbo spin echo (TSE) sequences, a T1W mDixon, and a T2W TSE navigated sequence acquired on end-expiration. All images were reconstructed in the axial plane. Images were assessed for image quality and appropriateness for use within the treatment pathway using visual grading analysis (VGA). An artefact in the right breast was noted independently by all observers. The patient's skin and medical notes were reviewed for possible explanation. The findings were discussed with the patient's responsible clinician, and subsequent referral to the local multi-disciplinary team (MDT) for radiologist review was made. On further investigation, the patient's images demonstrated a signal void in the subareolar region of the right breast coinciding with the surgical site. This was distal from the tumour bed and deemed unlikely to be related to a Magseed marker or intraoperative clips. The patient reported no history of nipple tattoo or piercing. There was nothing on clothing that this could be attributed to.

Discussion: Following MDT review, where all potential sources of signal void were considered, it was concluded that the cause was Magtrace, a superparamagnetic iron oxide tracer, recommended for sentinel lymph node localisation in patients with breast cancer in the United Kingdom. The artefact was characteristic of a magnetic susceptibility artefact. These can arise from local magnetic field inhomogeneities caused by the presence of the metal compounds in MagTrace. For breast MRIgRT on the MR-Linac, treatment verification and the possibility of real-time replanning is a critical aspect. The magnetic susceptibility artefact significantly inhibited plan adaption and confidence in the online image registration process making the patient ineligible for treatment on the MR-Linac.

Conclusion: As part of ongoing work-up for breast MRIgRT, the screening of patients for Magtrace is now included. Optimisation of MR imaging sequences for radiotherapy planning and image review to minimise distortion are being developed.