Clinical Experience of our 50 Consecutive Patients Treated on Pakistan First MR-Linac: Workflow Optimization and Early Outcomes from a Single Institution

Introduction: The integration of MRI with linear accelerators (MR-Linac) enables adaptive radiotherapy with superior soft tissue visualization. We report on our initial experience treating 50 consecutive patients, assessing clinical workflow, treatment feasibility, and early outcomes.

Methodology: Fifty patients underwent MR-guided radiotherapy on a 1.5T MR-Linac. Patients were selected based on tumor visibility, motion concerns, and potential benefit from online adaptive planning. Treatment sites included [e.g., Brain, Head and Neck, Breast and Chest wall, Esophagus, Lung, Liver, Bladder, Prostate, Rectum, Endometrium. Adaptive strategies (Adapt to Position/Shape) were utilized based on anatomical changes. Clinical workflow parameters, treatment duration, acute toxicity, and initial response were recorded.

Results: All 50 patients completed planned treatment with no grade ≥3 acute toxicity. Median on-couch time was 45 minutes. Adaptive planning was performed in 86% of fractions, reducing PTV margins by an average of 25%. Early indicated high patient comfort and satisfaction. Imaging quality allowed precise gating in 92% of cases. Prostate and rectal tumor cohorts showed promising early biochemical and radiographic responses.

Conclusion: This is Pakistan 1st MR-Linac experience demonstrates the clinical feasibility, safety, and potential benefits of MR-Linac guided adaptive radiotherapy. Ongoing follow-up will assess long-term control and late toxicity. MR-Linac offers a compelling platform for personalized radiotherapy and biologic adaptation. Our findings contribute to real-world evidence supporting wider implementation and refinement of MR-guided radiotherapy.

Conflict of interests: The authors declare no conflict of interest.

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

License: ©️ Author(s) 2026. This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, and unrestricted adaptation and reuse, including for commercial purposes, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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