S2990
Invited Speaker
ESTRO 2026
5281 Real-time tracking Emily A Hewson Image X Institute, The University of Sydney, Sydney, Australia Recent advancements have seen a shift toward hypofractionated radiation therapy with recent studies reporting superior patient outcomes. However as radiation therapy delivery trends toward increasingly conformal doses with stricter treatment margins and OAR constraints, the need for accurate motion management strategies that account for the complex, variable nature of human anatomy has become more critical than ever. An important component in the real- time intrafraction adaptation framework is tracking, where the treatment beam delivery is dynamically modified to adapt to the observed motion within a patient. There have been a number of tracking strategies developed that utilise specialised systems equipped with robotic or gimballed linacs, as well as strategies that take advantage of equipment on standard linacs through MLC tracking. Rather than tracking using the radiation beam, approaches that adjust the patient position in real time have also been explored through couch tracking. More complex tracking strategies can also account for deformable anatomies and multiple targets. Recently developed tracking strategies have strived toward performing dose-guided tracking, linking adaptation decisions with the metric more closely associated with patient outcomes. The ideal goal for tracking would be to achieve real-time customisation of the radiation to the patient’s full anatomy, maximising the dose to the tumour while minimising dose to the OARs, improving patient outcomes. However, several technical and practical challenges still need to be addressed before widespread clinical implementation can be achieved. 5282 Real-time segmentation Jennifer Pursley Radiation Oncology, Mayo Clinic, Rochester, USA This joint ESTRO-AAPM session will highlight emerging strategies for real-time intra-fraction adaptation and their potential to improve precision in radiation therapy delivery. Drawing on lessons from tracking- enabled platforms such as Vero, the session will explore how motion management has evolved from marker-based to marker-free approaches across moving targets including lung, liver, and pancreas. It will then address key enabling technologies, including real-time segmentation and quality assurance of auto- generated structures, as well as clinically available and emerging real-time tracking solutions, spanning
capture of outcomes across the prostate cancer pathway, the NPCA enables transparent public reporting and institutional accountability, driving measurable improvements in both treatment delivery and patient outcomes. A key innovation of the NPCA has been the development of the first national radiotherapy reporting programme focused on treatment related adverse events. Using linked datasets, including the cancer registry, Radiotherapy Dataset (RTDS) and Hospital Episode Statistics (HES), the audit has established reproducible, clinically meaningful indicators that support national benchmarking. These analyses have generated important insights into radiotherapy practice, including demonstrating reduced toxicity with intensity modulated radiotherapy compared with 3D conformal techniques, while supporting the safety of hypofractionated regimens. National benchmarking across approximately 50 radiotherapy centres enables identification of unwarranted variation in outcomes. Analytical approaches such as funnel plots highlight both negative and positive outliers, providing a foundation for targeted quality improvement. These findings have helped identify key drivers of variation, including contouring practices, treatment margins, image guidance, dosimetry and bowel and bladder preparation protocols. Importantly, the NPCA demonstrates that audit, when combined with transparent reporting and strong clinician engagement, can drive sustained improvements in care. Centres identified as outliers have shown measurable improvement over time, while high performing institutions act as exemplars for shared learning. A comparable national approach has already been established for systemic therapy, reinforcing the broader applicability of this model across oncology. This work highlights the critical role of national clinical audit in translating data into action and provides a scalable framework for radiotherapy quality improvement internationally. References: 1. Aggarwal A, Cromwell D, Nossiter J, et al. The National Cancer Audit Collaborating Centre (NATCAN): improving the quality of National Health Service cancer care in England and Wales. Lancet Oncol 2025;26(4):e225-e32. doi: 10.1016/s1470- 2045(24)00665-x 2. Aggarwal A, Nossiter J, Parry M, et al. Public reporting of outcomes in radiation oncology: the National Prostate Cancer Audit. Lancet Oncology 2021;22(5):e207-e15. doi:https://dx.doi.org/10.1016/S1470-2045(20)30558-1
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