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. 2025 Jan 23:15:1382537.
doi: 10.3389/fonc.2025.1382537. eCollection 2025.

Proof of concept of fully automated adaptive workflow for head and neck radiotherapy treatments with a conventional linear accelerator

Gaia Muti  1 , Marco M J Felisi  1 , Angelo F Monti  1 , Chiara Carsana  2 , Roberto Pellegrini  3 , Edoardo Salmeri  3 , Mauro Palazzi  2 , Paola E Colombo  1
Affiliations

Proof of concept of fully automated adaptive workflow for head and neck radiotherapy treatments with a conventional linear accelerator

Gaia Muti et al. Front Oncol. .

Abstract

Introduction: The objective of this study is to evaluate the performance of an automatic workflow for head-and-neck (H&N) radiotherapy using a multi-atlas based auto-contouring software and an a-priori multicriteria plan optimization algorithm and implement an adaptive online approach with CBCT images. Two different modalities are investigated, the fluence-to-position (FTP) and the adapt-to-shape (ATS) approach.

Materials and methods: Nine patients are used for the multi-atlas database. The organs at risk (OARs) of the H&N district and five additional structures (air, fat, tissue, bone and patient's exterior) subsequently used for the creation of the synthetic CT are auto-contoured with the Elekta ADMIRE® software. The mCycle algorithm is used for the a-priori multicriteria plan calculation. A total of twenty H&N patients are selected for this step. The automatic plans are compared to manual VMAT plans by assessing differences in planning time, dose delivered to targets and OARs, and calculating the plan quality indexes (PQIs). Two patients are chosen for the retrospective CBCT adaptive online feasibility analysis. To assess the differences for the two adaptive modalities, the clinical goals for targets and OARs and the number of passed constraints are explored. An analysis of the timing for the different steps is carried out to assess its clinical applicability.

Result: The dice of the five HU layer structures range between 0.66 and 0.99. The mCycle auto-planning significantly reduces planning time, from 2 hours to 10 minutes. The radiotherapist deems all plans clinically acceptable, and in the majority of cases the automatic plan is the preference choice. The automatic plans enhance OARs sparing and preserve a good target coverage, this is also confirmed by the PQIs result. Comparing FTP and ATS modes in adaptive radiotherapy, ATS exhibits superior outcomes, mostly in the target coverage. In the FTP techniques target coverage is inadequate and statistically different from the accepted values. In the ATS the results align with the initial approved values. Using the ATS mode the planning time takes around 14 minutes and approximately 20 minutes for the entire treatment.

Conclusion: This study contributes to the advancement of automatic and adaptive radiotherapy, demonstrating the potential of an automated workflow in H&N treatments.

Keywords: CBCT; MCO; adapt to shape; auto-planning; fluence to position; offline adaptive radiotherapy; online adaptive radiotherapy.

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Conflict of interest statement

RP serves as Director of Clinical Science at Elekta, Ing. ES serves as Clinical Science Engineer at Elekta. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Diagram illustrating the key steps of the workflow.
Figure 2
Figure 2
Boxplot showing the time spent for the manual and automatic planning, semilog scale graph.
Figure 3
Figure 3
Boxplot showing the PTV1, PTV2 and PTV2−1 percentage difference coverage and PTV1 and PTV2−1 percentage difference hot-spots between the scheduled plan and the FTP plans and between the scheduled plan and the ATS plans, for patient A and B In the boxplot, the inner line denotes the median value, the box the interquartile range and the whiskers the minimum and maximum value excluding the outliers that are presented as single markers.
Figure 4
Figure 4
Boxplot showing the mean dose difference between the scheduled plan and the FTP plans and between the scheduled plan and the ATS plans, for patient A and B, only for OARs that are significantly different.
Figure 5
Figure 5
Boxplot showing the max dose difference between the scheduled plan and the FTP plans and between the scheduled plan and the ATS plans, for patient A and B, only for OARs that are significantly different.
See this image and copyright information in PMC

References

    1. Buciuman N, Marcu LG. Adaptive radiotherapy in head and neck cancer using volumetric modulated arc therapy. J Personalized Med. (2022) 12:668. doi: 10.3390/jpm12050668 - DOI - PMC - PubMed
    1. Green OL, Henke LE, Hugo GD. Practical clinical workflows for online and offline adaptive radiation therapy. Semin Radiat Oncol. (2019) 29:219–27. doi: 10.1016/j.semradonc.2019.02.004 - DOI - PMC - PubMed
    1. Boeke S, Mönnich D, van Timmeren JE, Balermpas P. Mr-guided radiotherapy for head and neck cancer: Current developments, perspectives, and challenges. Front Oncol. (2021) 11:616156. doi: 10.3389/fonc.2021.616156 - DOI - PMC - PubMed
    1. Rong Y, Smilowitz J, Tewatia D, Tomé WA, Paliwal B. Dose calculation on kv cone beam ct images: An investigation of the hu-density conversion stability and dose accuracy using the site-specific calibration. Med Dosimetry. (2010) 35:195–207. doi: 10.1016/j.meddos.2009.06.001 - DOI - PubMed
    1. Yoon SW, Lin H, Alonso-Basanta M, Anderson N, Apinorasethkul O, Cooper K, et al. . Initial evaluation of a novel cone-beam ct-based semi-automated online adaptive radiotherapy system for head and neck cancer treatment – a timing and automation quality study. Cureus. (2020) 12:8. doi: 10.7759/cureus.9660 - DOI - PMC - PubMed

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