Magnetic resonance imaging (MRI) utilizes the magnetic properties of tissues to generate image-forming signals. MRI has exquisite soft-tissue contrast and since tumors are mainly soft-tissues, it offers improved delineation of the target volume and nearby organs at risk. The proposed Magnetic Resonance-only Radiotherapy (MR-only RT) work flow allows for the use of MRI as the sole imaging modality in the radiotherapy (RT) treatment planning of cancer. There are, however, issues with geometric distortions inherent with MR image acquisition processes. These distortions result from imperfections in the main magnetic field, nonlinear gradients, as well as field disturbances introduced by the imaged object. In this thesis, we quantified the effect of system related and patient-induced susceptibility geometric distortions on dose distributions for prostate as well as head and neck cancers. Methods to mitigate these distortions were also studied. In Study I, mean worst system related residual distortions of 3.19, 2.52 and 2.08 mm at bandwidths (BW) of 122, 244 and 488 Hz/pixel up to a radial distance of 25 cm from a 3T PET/MR scanner was measured with a large field of view (FoV) phantom. Subsequently, we estimated maximum shifts of 5.8, 2.9 and 1.5 mm due to patient-induced susceptibility distortions. VMAT-optimized treatment plans initially performed on distorted CT (dCT) images and recalculated on real CT datasets resulted in a dose difference of less than 0.5%.  The magnetic susceptibility differences at tissue-metallic,-air and -bone interfaces result in local B0 magnetic field inhomogeneities. The distortion shifts caused by these field inhomogeneities can be reduced by shimming.  Study II aimed to investigate the use of shimming to improve the homogeneity of local  B0 magnetic field which will be beneficial for radiotherapy applications. A shimming simulation based on spherical harmonics modeling was developed. The spinal cord, an organ at risk is surrounded by bone and in close proximity to the lungs may have high susceptibility differences. In this region, mean pixel shifts caused by local B0 field inhomogeneities were reduced from 3.47±1.22 mm to 1.35±0.44 mm and 0.99±0.30 mm using first and second order shimming respectively. This was for a bandwidth of 122 Hz/pixel and an in-plane voxel size of 1×1 mm2.  Also examined in Study II as in Study I was the dosimetric effect of geometric distortions on 21 Head and Neck cancer treatment plans. The dose difference in D50 at the PTV between distorted CT and real CT plans was less than 1.0%. In conclusion, the effect of MR geometric distortions on dose plans was small. Generally, we found patient-induced susceptibility distortions were larger compared with residual system distortions at all delineated structures except the external contour. This information will be relevant when setting margins for treatment volumes and organs at risk.   The current practice of characterizing MR geometric distortions utilizing spatial accuracy phantoms alone may not be enough for an MR-only radiotherapy workflow. Therefore, measures to mitigate patient-induced susceptibility effects in clinical practice such as patient-specific correction algorithms are needed to complement existing distortion reduction methods such as high acquisition bandwidth and shimming.

In todays Radiotherapy Treatment Planning, RTP, it is common to use Computed Tomography, CT, together with Magnetic Resonance Imaging, MRI, where CT provides electron density information and a geometrical reference, and where MRI provides superior soft tissue contrast. To sim- plify the workflow and improve treatment accuracy, research groups have demonstrated how to exclude CT and use a MRI-only approach. In this thesis, a method for spatial distortion analysis, ultimately enabling quality assurance, QA, of the spatial accuracy of MRI, was defined, tested and evaluated. A phantom was built to cover the entire clinical Field Of View, FOV, and 6mm-diameter fluid filled paintball markers were placed in a well-defined geometrical pattern within the phantom, and used as positive contrast. The phantom was imaged with a 3D Fast Gradient Echo sequence and a 3D Fast Spin Echo sequence. The markers were identified in the image data by a MATLAB-algorithm, and the location of the center of mass was calculated for each marker and compared to a theoretical reference. The location error was defined as the spatial distortion - a measurement of the spatial accuracy. Imaging parameters were altered and the effect on the spatial accuracy was analyzed. The spatial distortions were successfully measured within the entire (maximal) clinical FOV. It was shown that high readout bandwidth reduced distortions in the frequency encoding direction. These distortions could thus be attributed to B0-inhomogeneities. It was also determined that increasing the readout bandwidth to the maximum value reduced the maximum distortions in the frequency encoding direction to the same level as the maximum distortions in the other two phase-encoding directions of the 3D acquisitions. The voxel size had a very small effect on the spatial accuracy, enabling large voxelsize to be used when imaging the phantom, to decrease the scan time. The method was deemed capable of serving as a basis for QA of the spatial accuracy of large FOV MRI, which is needed in future MRI-only RTP approaches.