Test-Retest Apparent Diffusion Coefficient Reproducibility in Head and Neck Cancer Using a 1.5-T MR-Linac

Purpose To evaluate the reproducibility of apparent diffusion coefficient (ADC) measurements in head and neck squamous cell carcinoma (HNSCC) using a 1.5-T MR-linac (MRI-guided linear accelerator) system. Materials and Methods In this retrospective study, conducted between February 2021 and January 2024, patients with HNSCC lesions underwent echo-planar imaging diffusion-weighted MRI on a 1.5-T MR-linac system at two time points before the start of radiation therapy. Mean and median ADC values and volumes were measured for each lesion. Absolute and percent reproducibility coefficients (RCs) were calculated. Linear regression analyses and F tests were performed to determine whether the lesion volume or time between scans impacted reproducibility. Results The final cohort consisted of 37 patients (36 male, one female; median age, 63 years [IQR, 47-80 years]), with 34 primary tumors and 55 lymph nodes included in the analysis. For primary tumors and lymph nodes, the median of the mean ADC, median ADC, and volume were 1.19 × 10^-3 mm²/sec (IQR, 1.01-1.34 × 10^-3 mm²/sec) and 1.02 × 10^-3 mm²/sec (IQR, 0.88-1.33 × 10^-3 mm²/sec), 1.16 × 10^-3 mm²/sec (IQR, 0.99-1.36 × 10^-3 mm²/sec) and 1.03 × 10^-3 mm²/sec (IQR, 0.90-1.35 × 10^-3 mm²/sec), and 2.9 cm³ (IQR, 1.5-8.9 cm³) and 3.6 cm³ (IQR, 1.7-8.3 cm³), respectively. The respective RC values of mean ADC were 0.365 × 10^-3 mm²/sec and 0.355 × 10^-3 mm²/sec for tumors and lymph nodes, and the respective percent RC values were 29.9% and 31.1%; similar values were obtained for the median ADC. Reproducibility did not correlate with either the lesion volume or scan interval, but a trend toward poorer reproducibility with smaller volumes was observed. Conclusion This MR-linac sequence demonstrated acceptable reproducibility for detecting larger ADC changes but might still miss some clinically significant changes. Keywords: Radiation Therapy, MR-Diffusion Weighted Imaging, Radiation Therapy/Oncology, Head/Neck © RSNA 2026 Supplemental material is available for this article.