S2122
Physics - Inter-fraction motion management and daily adaptive radiotherapy
ESTRO 2026
Netherlands. 4 HollandPTC, HollandPTC, Delft, Netherlands. 5 Faculty of Nuclear Sciences and Physical Engineering, Czech Technical University in Prague, Prague, Czech Republic. 6 Proton Therapy Center, Czech, Prague, Czech Republic. 7 Faculty of Medicine Carl Gustav Carus, TUD Dresden University of Technology, Dresden, Germany. 8 The Skandion Clinic, SA, Uppsala, Sweden. 9 Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden. 10 Danish Centre for Particle Therapy, Aarhus University hospital, Aarhus, Denmark and Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark. 11 Cancer Clinic, Haukeland University Hospital, Bergen, Norway. 12 University College London Hospital, UCLH, London, United Kingdom. 13 Cyclotron Centre, Bronowice, Cracow, Poland. 14 Clinical Cooperation Unit Translational Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany. 15 Department of Radiation Oncology and Heidelberg Ion Beam Therapy Center, Heidelberg University Hospital, Heidelberg, Germany. 16 Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark. 17 West German Protontherapy Centre Essen, WPE, Essen, Germany. 18 Department of Radiation Oncology (Maastro Clinic), GROW School for Oncology, Maastricht University Medical Centre, Maastricht, Netherlands. 19 Fisica Sanitaria, Proton therapy centre APSS, Trento, Italy. 20 Proton beam therapy center, the Christie, Manchester, United Kingdom. 21 MedAustron, Centre for Ion Therapy, Wiener Neustadt, Austria. 22 Center for Proton Therapy, Paul Scherrer Institut – PSI, Villigen, Switzerland. 23 Karl Landsteiner University, for Health Sciences, Krems, Austria. 24 Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany Purpose/Objective: For many indications in particle therapy (PT), anatomical changes often necessitate plan adaptations, leading to an increasing interest in efficient and flexible adaptive workflows. This survey aimed to provide an overview of the current status and future plans for imaging in adaptive PT across Europe. Material/Methods: The survey consisted of 39 questions on the current and planned use of imaging in adaptive PT, its requirements, commissioning and QA and was developed as part of a European Particle Therapy Network (EPTN) initiative. The survey was distributed to all European PT centers. Responses were collected between August and October 2025. Results: Fifteen PT centers from ten countries with varying
years of experience responded (figure 1a). All participating centers reported having adaptive protocols in place. All perform offline adaptation (for a subsequent fraction, patient leaves couch), either triggered (15/15) or scheduled (4/15). One center additionally performs online adaptation (patient remains on the treatment couch between imaging and delivery of the adaptive plan) (figure 1b). All adaptive plans are optimized on fan-beam CTs. For adaptive contouring and adaptive decision making, additional CBCT and MRI scans are used (10/15) (figure 2). Poor CBCT image quality and limited availability were identified as major limitations (9/15) for the implementation of advanced adaptive workflows.Eight centers plan to implement a new adaptive workflow within the next 3-5 years. Planned developments include new triggered or scheduled offline adaptation workflows (7/15) as well as online adaptative workflows (8/15). Five centers plan to implement CBCT-based plan optimization, and two plan MRI- based optimization via synthetic CT images. Nine centers plan to integrate artificial intelligence or deformable image registration based synthetic imaging as some part of their workflow, using CBCT (9/15) or MRI (4/15). The biggest limitations are the lack of appropriate technologies and/or approved tools. Nine centers expect changes in requirements, commissioning and QA, especially when implementing synthetic CT images.
Conclusion: Compared to the POP-ART survey from 2023 [1], where only 84% of centers had adaptive protocols in place, in this survey all participating centers perform clinical adaptive PT. There is a strong interest in
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