Zheng Dandan, Cummings Michael, Zhang Hong, Podgorsak Alexander, Li Fiona, Dona Lemus Olga, Webster Matthew, Joyce Neil, Hagenbach Erika, Bylund Kevin, Qiu Haoming, Pacella Matthew, Chen Yuhchyau, Tanny Sean
Department of Radiation Oncology, University of Rochester, Rochester, NY 14627, USA.
Department of Radiation Oncology, University of Miami, Coral Gables, FL 33146, USA.
Cancers (Basel). 2025 Apr 26;17(9):1462. doi: 10.3390/cancers17091462.
Cone-beam computed tomography (CBCT)-guided online adaptive radiotherapy (oART) represents a significant advancement in radiation oncology, enabling on-couch plan adaptation to account for daily anatomical changes. While this automation improves precision and workflow efficiency, it also introduces new failure modes (FMs) and workflow irregularities. This study aimed to systematically evaluate the clinical and technical challenges associated with CBCT-guided oART implementation. We retrospectively analyzed over 1000 CBCT-guided oART sessions for pelvic malignancies performed at our institution. A multidisciplinary team conducted a comprehensive review to identify and classify FMs, followed by root cause analysis (RCA) to evaluate their impact on treatment safety, efficacy, and workflow robustness. In addition to session-terminating FMs, we identified recurring failure modes across three major domains: (1) system-driven issues, such as rigid target localization and software-driven irregularities; (2) patient-driven challenges, including interfractional and intrafractional anatomical variations; and (3) treatment planning and execution failures, including excessive dose hotspots from field-of-view limitations. The system's closed-loop automation, while streamlining processes, introduced rigid constraints in plan adaptation and fallback plan execution, occasionally leading to unintended dose discrepancies. This study provides a comprehensive clinical practice-based evaluation of CBCT-guided oART, highlighting system-specific failure modes and their implications. Addressing these challenges requires structured quality assurance processes, multidisciplinary collaboration, and continuous workflow refinement. Our findings contribute to the development of safer and more robust adaptive radiotherapy platforms and clinical workflows.
锥形束计算机断层扫描（CBCT）引导的在线自适应放射治疗（oART）是放射肿瘤学的一项重大进展，能够在治疗床上对计划进行调整，以适应每日的解剖结构变化。虽然这种自动化提高了精度和工作流程效率，但也引入了新的故障模式（FMs）和工作流程异常情况。本研究旨在系统评估与CBCT引导的oART实施相关的临床和技术挑战。我们回顾性分析了在我们机构进行的1000多例针对盆腔恶性肿瘤的CBCT引导的oART治疗疗程。一个多学科团队进行了全面审查，以识别和分类故障模式，随后进行根本原因分析（RCA），以评估它们对治疗安全性、疗效和工作流程稳健性的影响。除了导致疗程终止的故障模式外，我们还在三个主要领域识别出了反复出现的故障模式：（1）系统驱动的问题，如刚性靶区定位和软件驱动的异常情况；（2）患者驱动的挑战，包括分次间和分次内的解剖结构变化；（3）治疗计划和执行失败，包括由于视野限制导致的过量剂量热点。该系统的闭环自动化在简化流程的同时，在计划调整和备用计划执行方面引入了刚性约束，偶尔会导致意外的剂量差异。本研究基于临床实践对CBCT引导的oART进行了全面评估，突出了特定系统的故障模式及其影响。应对这些挑战需要结构化的质量保证流程、多学科协作以及持续的工作流程优化。我们的研究结果有助于开发更安全、更稳健的自适应放射治疗平台和临床工作流程。
