Benefits of daily online plan adaptation with reduced margins in neoadjuvant chemoradiotherapy for esophageal cancer

Leigh A P Bruijs; Thomas Weststrate; Karin N Goudschaal; Irma W E M van Dijk; Jorrit Visser; Joost J C Verhoeff; Zdenko van Kesteren; Tezontl S Rosario; Arjan Bel; Peter S N van Rossum

doi:10.1016/j.phro.2026.100946

Benefits of daily online plan adaptation with reduced margins in neoadjuvant chemoradiotherapy for esophageal cancer

^*Corresponding author for this work

Amsterdam UMC location University of Amsterdam
Amsterdam UMC Location Vrije Universiteit Amsterdam
The Netherlands

Research output: Contribution to journal › Article › Academic › peer-review

Abstract

Background and purpose:Image-guided radiotherapy (IGRT) for esophageal cancer requires large planning target volume (PTV) margins to account for interfraction variations, increasing radiation-associated side-effects. Cone-beam computed tomography-based (CBCT) online adaptive radiotherapy (oART) enables daily contour and plan adaptation, addressing anatomical changes and allowing for reduced PTV margins while ensuring target coverage. This study compared the dose-volume parameters of daily oART to non-adaptive IGRT in patients with esophageal cancer.Material and methodsTen patients with distal esophageal or gastroesophageal junction cancer who received neoadjuvant chemoradiotherapy (41.4 Gy/23 fractions) were included retrospectively. Daily IGRT CBCTs were used to emulate oART with artificial intelligence (AI)-assisted target and organs-of-interest contouring, manual edits when necessary, and adaptive re-optimization. PTV margins (Anterior-Posterior, Left-Right, Caudal-Cranial) were reduced from 5, 7, 10 mm (IGRT) to 3, 5, 5 mm (oART), respectively. Mean organs-of-interest and fraction-equivalent (FE) dose-volume metrics between delivered and adaptive plans were compared.ResultsCompared with IGRT, oART plans significantly reduced the number of fractions with internal clinical target volume underdosing (V_95% < 98%: n = 32 vs. n = 1 fraction; p = 0.002) and median hotspot dose (D0.1cm3[jls-end-space/]: 106.2% vs. 103.9%; p = 0.002). Mean heart dose decreased by 10% (p = 0.037), and heart FE-V_30Gy by 42% (7.3% vs. 4.3%; p = 0.002). Mean lung dose was reduced by 11% (p = 0.002), lung FE-V_20Gy by 39% (4.2% vs. 2.6%; p = 0.002), and lung FE-V_10Gy by 22% (24.6% vs. 19.3%; p = 0.002).ConclusionCBCT-based oART improved dose distribution in esophageal cancer by enabling PTV margin reduction, improved target coverage and superior organs-of-interest sparing. These findings encourage clinical implementation to reduce radiation-associated side-effects.

Original language	English
Article number	100946
Pages (from-to)	100946
Journal	Physics and Imaging in Radiation Oncology
Volume	38
DOIs	https://doi.org/10.1016/j.phro.2026.100946
Publication status	Published - Mar 2026

Keywords

Chemoradiotherapy
Esophageal cancer
IGRT
Online adaptive
Radiotherapy

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10.1016/j.phro.2026.100946

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Bruijs, L. A. P., Weststrate, T., Goudschaal, K. N., van Dijk, I. W. E. M., Visser, J., Verhoeff, J. J. C., van Kesteren, Z., Rosario, T. S., Bel, A., & van Rossum, P. S. N. (2026). Benefits of daily online plan adaptation with reduced margins in neoadjuvant chemoradiotherapy for esophageal cancer. Physics and Imaging in Radiation Oncology, 38, 100946. Article 100946. https://doi.org/10.1016/j.phro.2026.100946

@article{f3ba6e83be964777a8368f164982be29,

title = "Benefits of daily online plan adaptation with reduced margins in neoadjuvant chemoradiotherapy for esophageal cancer",

abstract = "Background and purpose:Image-guided radiotherapy (IGRT) for esophageal cancer requires large planning target volume (PTV) margins to account for interfraction variations, increasing radiation-associated side-effects. Cone-beam computed tomography-based (CBCT) online adaptive radiotherapy (oART) enables daily contour and plan adaptation, addressing anatomical changes and allowing for reduced PTV margins while ensuring target coverage. This study compared the dose-volume parameters of daily oART to non-adaptive IGRT in patients with esophageal cancer.Material and methodsTen patients with distal esophageal or gastroesophageal junction cancer who received neoadjuvant chemoradiotherapy (41.4 Gy/23 fractions) were included retrospectively. Daily IGRT CBCTs were used to emulate oART with artificial intelligence (AI)-assisted target and organs-of-interest contouring, manual edits when necessary, and adaptive re-optimization. PTV margins (Anterior-Posterior, Left-Right, Caudal-Cranial) were reduced from 5, 7, 10 mm (IGRT) to 3, 5, 5 mm (oART), respectively. Mean organs-of-interest and fraction-equivalent (FE) dose-volume metrics between delivered and adaptive plans were compared.ResultsCompared with IGRT, oART plans significantly reduced the number of fractions with internal clinical target volume underdosing (V95\% < 98\%: n = 32 vs. n = 1 fraction; p = 0.002) and median hotspot dose (D0.1cm3[jls-end-space/]: 106.2\% vs. 103.9\%; p = 0.002). Mean heart dose decreased by 10\% (p = 0.037), and heart FE-V30Gy by 42\% (7.3\% vs. 4.3\%; p = 0.002). Mean lung dose was reduced by 11\% (p = 0.002), lung FE-V20Gy by 39\% (4.2\% vs. 2.6\%; p = 0.002), and lung FE-V10Gy by 22\% (24.6\% vs. 19.3\%; p = 0.002).ConclusionCBCT-based oART improved dose distribution in esophageal cancer by enabling PTV margin reduction, improved target coverage and superior organs-of-interest sparing. These findings encourage clinical implementation to reduce radiation-associated side-effects.",

keywords = "Chemoradiotherapy, Esophageal cancer, IGRT, Online adaptive, Radiotherapy",

author = "Bruijs, \{Leigh A P\} and Thomas Weststrate and Goudschaal, \{Karin N\} and \{van Dijk\}, \{Irma W E M\} and Jorrit Visser and Verhoeff, \{Joost J C\} and \{van Kesteren\}, Zdenko and Rosario, \{Tezontl S\} and Arjan Bel and \{van Rossum\}, \{Peter S N\}",

note = "Publisher Copyright: {\textcopyright} 2026 The Authors. Published by Elsevier B.V. on behalf of European Society of Radiotherapy \& Oncology. This is an open access article under the CC BY license. http://creativecommons.org/licenses/by/4.0/",

year = "2026",

month = mar,

doi = "10.1016/j.phro.2026.100946",

language = "English",

volume = "38",

pages = "100946",

journal = "Physics and Imaging in Radiation Oncology",

issn = "2405-6316",

publisher = "Elsevier Ireland Ltd",

}

Bruijs, LAP , Weststrate, T , Goudschaal, KN , van Dijk, IWEM , Visser, J , Verhoeff, JJC , van Kesteren, Z , Rosario, TS , Bel, A & van Rossum, PSN 2026, 'Benefits of daily online plan adaptation with reduced margins in neoadjuvant chemoradiotherapy for esophageal cancer', Physics and Imaging in Radiation Oncology, vol. 38, 100946, pp. 100946. https://doi.org/10.1016/j.phro.2026.100946

TY - JOUR

T1 - Benefits of daily online plan adaptation with reduced margins in neoadjuvant chemoradiotherapy for esophageal cancer

AU - Bruijs, Leigh A P

AU - Weststrate, Thomas

AU - Goudschaal, Karin N

AU - van Dijk, Irma W E M

AU - Visser, Jorrit

AU - Verhoeff, Joost J C

AU - van Kesteren, Zdenko

AU - Rosario, Tezontl S

AU - Bel, Arjan

AU - van Rossum, Peter S N

N1 - Publisher Copyright: © 2026 The Authors. Published by Elsevier B.V. on behalf of European Society of Radiotherapy & Oncology. This is an open access article under the CC BY license. http://creativecommons.org/licenses/by/4.0/

PY - 2026/3

Y1 - 2026/3

N2 - Background and purpose:Image-guided radiotherapy (IGRT) for esophageal cancer requires large planning target volume (PTV) margins to account for interfraction variations, increasing radiation-associated side-effects. Cone-beam computed tomography-based (CBCT) online adaptive radiotherapy (oART) enables daily contour and plan adaptation, addressing anatomical changes and allowing for reduced PTV margins while ensuring target coverage. This study compared the dose-volume parameters of daily oART to non-adaptive IGRT in patients with esophageal cancer.Material and methodsTen patients with distal esophageal or gastroesophageal junction cancer who received neoadjuvant chemoradiotherapy (41.4 Gy/23 fractions) were included retrospectively. Daily IGRT CBCTs were used to emulate oART with artificial intelligence (AI)-assisted target and organs-of-interest contouring, manual edits when necessary, and adaptive re-optimization. PTV margins (Anterior-Posterior, Left-Right, Caudal-Cranial) were reduced from 5, 7, 10 mm (IGRT) to 3, 5, 5 mm (oART), respectively. Mean organs-of-interest and fraction-equivalent (FE) dose-volume metrics between delivered and adaptive plans were compared.ResultsCompared with IGRT, oART plans significantly reduced the number of fractions with internal clinical target volume underdosing (V95% < 98%: n = 32 vs. n = 1 fraction; p = 0.002) and median hotspot dose (D0.1cm3[jls-end-space/]: 106.2% vs. 103.9%; p = 0.002). Mean heart dose decreased by 10% (p = 0.037), and heart FE-V30Gy by 42% (7.3% vs. 4.3%; p = 0.002). Mean lung dose was reduced by 11% (p = 0.002), lung FE-V20Gy by 39% (4.2% vs. 2.6%; p = 0.002), and lung FE-V10Gy by 22% (24.6% vs. 19.3%; p = 0.002).ConclusionCBCT-based oART improved dose distribution in esophageal cancer by enabling PTV margin reduction, improved target coverage and superior organs-of-interest sparing. These findings encourage clinical implementation to reduce radiation-associated side-effects.

AB - Background and purpose:Image-guided radiotherapy (IGRT) for esophageal cancer requires large planning target volume (PTV) margins to account for interfraction variations, increasing radiation-associated side-effects. Cone-beam computed tomography-based (CBCT) online adaptive radiotherapy (oART) enables daily contour and plan adaptation, addressing anatomical changes and allowing for reduced PTV margins while ensuring target coverage. This study compared the dose-volume parameters of daily oART to non-adaptive IGRT in patients with esophageal cancer.Material and methodsTen patients with distal esophageal or gastroesophageal junction cancer who received neoadjuvant chemoradiotherapy (41.4 Gy/23 fractions) were included retrospectively. Daily IGRT CBCTs were used to emulate oART with artificial intelligence (AI)-assisted target and organs-of-interest contouring, manual edits when necessary, and adaptive re-optimization. PTV margins (Anterior-Posterior, Left-Right, Caudal-Cranial) were reduced from 5, 7, 10 mm (IGRT) to 3, 5, 5 mm (oART), respectively. Mean organs-of-interest and fraction-equivalent (FE) dose-volume metrics between delivered and adaptive plans were compared.ResultsCompared with IGRT, oART plans significantly reduced the number of fractions with internal clinical target volume underdosing (V95% < 98%: n = 32 vs. n = 1 fraction; p = 0.002) and median hotspot dose (D0.1cm3[jls-end-space/]: 106.2% vs. 103.9%; p = 0.002). Mean heart dose decreased by 10% (p = 0.037), and heart FE-V30Gy by 42% (7.3% vs. 4.3%; p = 0.002). Mean lung dose was reduced by 11% (p = 0.002), lung FE-V20Gy by 39% (4.2% vs. 2.6%; p = 0.002), and lung FE-V10Gy by 22% (24.6% vs. 19.3%; p = 0.002).ConclusionCBCT-based oART improved dose distribution in esophageal cancer by enabling PTV margin reduction, improved target coverage and superior organs-of-interest sparing. These findings encourage clinical implementation to reduce radiation-associated side-effects.

KW - Chemoradiotherapy

KW - Esophageal cancer

KW - IGRT

KW - Online adaptive

KW - Radiotherapy

UR - https://www.scopus.com/pages/publications/105034552969

U2 - 10.1016/j.phro.2026.100946

DO - 10.1016/j.phro.2026.100946

M3 - Article

C2 - 41889669

SN - 2405-6316

VL - 38

SP - 100946

JO - Physics and Imaging in Radiation Oncology

JF - Physics and Imaging in Radiation Oncology

M1 - 100946

ER -

Benefits of daily online plan adaptation with reduced margins in neoadjuvant chemoradiotherapy for esophageal cancer

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