Cone beam computed tomography-guided online adaptive radiation therapy: Clinical implementation in breast and axillary target volumes

Angelique R. W. van Vlaenderen; Judith G. Middelburg-van Rijn; Koen J. Nelissen; Karin N. Goudschaal; Lars ter Beek; Jessica van der Himst; Cassey E. Glebbeek; Lisette M. van Maurik; Amber L. Bakker; Nina Bijker; Joost J. C. Verhoeff; Ben J. Slotman; Anna Dinkla; Wilko F. A. R. Verbakel; Desirée H. J. G. van den Bongard

doi:10.1016/j.ctro.2025.101086

Cone beam computed tomography-guided online adaptive radiation therapy: Clinical implementation in breast and axillary target volumes

Angelique R. W. van Vlaenderen^*
, Judith G. Middelburg-van Rijn^*
, Koen J. Nelissen^*
, Karin N. Goudschaal^*
, Lars ter Beek^*
, Jessica van der Himst^*
, Cassey E. Glebbeek^*
, Lisette M. van Maurik^*
, Amber L. Bakker^*
, Nina Bijker
, Joost J. C. Verhoeff
, Ben J. Slotman
, Anna Dinkla
, Wilko F. A. R. Verbakel
, Desirée H. J. G. van den Bongard

^*Corresponding author for this work

Vrije Universiteit Amsterdam
Amsterdam UMC
CCA - Cancer Treatment and Quality of Life
Universiteit van Amsterdam
Varian Medical Systems
CCA – Cancer biology and immunology

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

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Abstract

Background and purpose: Daily differences in breast contour and arm positioning can result in frequent re-positioning and offline re-planning in postoperative breast radiotherapy (RT). Online adaptive radiotherapy (oART) enables daily adaptation of the radiotherapy treatment plan. This study aimed to implement oART in breast and axillary target volumes to eliminate the need for repositioning and replanning. Materials and methods: Patients referred for postoperative partial breast irradiation (PBI) and whole breast irradiation (WBI)/post-mastectomy radiotherapy (PMRT) with or without axillary levels I-II (5x5.2 Gy) or I-IV (15x2.67 Gy) were included. On-couch treatment times were evaluated as well as dosimetry, target volume, acute toxicity, and in-house satisfaction questionnaires. Results: Seventy-nine patients (n = 66 PBI/WBI/PMRT, n = 13 WBI + axillary levels I-II/I-IV) were treated with postoperative RT (465 fractions). On-couch median time ranged from 14.5 (range: 10.1–29.2) minutes for right-sided WBI to 25.8 (range: 22.6–36.8) minutes for left-sided WBI + axillary levels I-II. All adapted treatment plans met the D98% ≥ 95 % coverage criteria for the target PTV. Relative breast CTV volumes for the adapted plan decreased in fraction 1 and increased in fractions 2–5 compared to the CTV volume on the planning CT. Toxicity was mainly grades 0 and 1 and patient satisfaction was good. Conclusion: Implementation of oART was feasible in all breast target volumes with acceptable treatment duration, only mild acute toxicity, favorable patient-reported comfort, and dosimetry that met clinical standards. Future work will focus on the implementation of oART in RT boost indications, and selection of breast cancer patients who will benefit most from oART.

Original language	English
Article number	101086
Journal	Clinical and Translational Radiation Oncology
Volume	56
DOIs	https://doi.org/10.1016/j.ctro.2025.101086
Publication status	Published - 1 Jan 2026

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van Vlaenderen, A. R. W., Middelburg-van Rijn, J. G., Nelissen, K. J., Goudschaal, K. N., ter Beek, L., van der Himst, J., Glebbeek, C. E., van Maurik, L. M., Bakker, A. L., Bijker, N., Verhoeff, J. J. C., Slotman, B. J., Dinkla, A., Verbakel, W. F. A. R., & van den Bongard, D. H. J. G. (2026). Cone beam computed tomography-guided online adaptive radiation therapy: Clinical implementation in breast and axillary target volumes. Clinical and Translational Radiation Oncology, 56, Article 101086. https://doi.org/10.1016/j.ctro.2025.101086

@article{e0603da8fbac4548a2d7f106779adfca,

title = "Cone beam computed tomography-guided online adaptive radiation therapy: Clinical implementation in breast and axillary target volumes",

abstract = "Background and purpose: Daily differences in breast contour and arm positioning can result in frequent re-positioning and offline re-planning in postoperative breast radiotherapy (RT). Online adaptive radiotherapy (oART) enables daily adaptation of the radiotherapy treatment plan. This study aimed to implement oART in breast and axillary target volumes to eliminate the need for repositioning and replanning. Materials and methods: Patients referred for postoperative partial breast irradiation (PBI) and whole breast irradiation (WBI)/post-mastectomy radiotherapy (PMRT) with or without axillary levels I-II (5x5.2 Gy) or I-IV (15x2.67 Gy) were included. On-couch treatment times were evaluated as well as dosimetry, target volume, acute toxicity, and in-house satisfaction questionnaires. Results: Seventy-nine patients (n = 66 PBI/WBI/PMRT, n = 13 WBI + axillary levels I-II/I-IV) were treated with postoperative RT (465 fractions). On-couch median time ranged from 14.5 (range: 10.1–29.2) minutes for right-sided WBI to 25.8 (range: 22.6–36.8) minutes for left-sided WBI + axillary levels I-II. All adapted treatment plans met the D98\% ≥ 95 \% coverage criteria for the target PTV. Relative breast CTV volumes for the adapted plan decreased in fraction 1 and increased in fractions 2–5 compared to the CTV volume on the planning CT. Toxicity was mainly grades 0 and 1 and patient satisfaction was good. Conclusion: Implementation of oART was feasible in all breast target volumes with acceptable treatment duration, only mild acute toxicity, favorable patient-reported comfort, and dosimetry that met clinical standards. Future work will focus on the implementation of oART in RT boost indications, and selection of breast cancer patients who will benefit most from oART.",

author = "\{van Vlaenderen\}, \{Angelique R. W.\} and \{Middelburg-van Rijn\}, \{Judith G.\} and Nelissen, \{Koen J.\} and Goudschaal, \{Karin N.\} and \{ter Beek\}, Lars and \{van der Himst\}, Jessica and Glebbeek, \{Cassey E.\} and \{van Maurik\}, \{Lisette M.\} and Bakker, \{Amber L.\} and Nina Bijker and Verhoeff, \{Joost J. C.\} and Slotman, \{Ben J.\} and Anna Dinkla and Verbakel, \{Wilko F. A. R.\} and \{van den Bongard\}, \{Desir{\'e}e H. J. G.\}",

note = "Publisher Copyright: {\textcopyright} 2025 The Authors",

year = "2026",

month = jan,

day = "1",

doi = "10.1016/j.ctro.2025.101086",

language = "English",

volume = "56",

journal = "Clinical and Translational Radiation Oncology",

issn = "2405-6308",

publisher = "Elsevier Ireland Ltd",

}

van Vlaenderen, ARW, Middelburg-van Rijn, JG, Nelissen, KJ , Goudschaal, KN, ter Beek, L, van der Himst, J, Glebbeek, CE, van Maurik, LM, Bakker, AL , Bijker, N , Verhoeff, JJC , Slotman, BJ , Dinkla, A , Verbakel, WFAR & van den Bongard, DHJG 2026, 'Cone beam computed tomography-guided online adaptive radiation therapy: Clinical implementation in breast and axillary target volumes', Clinical and Translational Radiation Oncology, vol. 56, 101086. https://doi.org/10.1016/j.ctro.2025.101086

Cone beam computed tomography-guided online adaptive radiation therapy: Clinical implementation in breast and axillary target volumes. / van Vlaenderen, Angelique R. W.; Middelburg-van Rijn, Judith G.; Nelissen, Koen J. et al.
In: Clinical and Translational Radiation Oncology, Vol. 56, 101086, 01.01.2026.

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

TY - JOUR

T1 - Cone beam computed tomography-guided online adaptive radiation therapy

T2 - Clinical implementation in breast and axillary target volumes

AU - van Vlaenderen, Angelique R. W.

AU - Middelburg-van Rijn, Judith G.

AU - Nelissen, Koen J.

AU - Goudschaal, Karin N.

AU - ter Beek, Lars

AU - van der Himst, Jessica

AU - Glebbeek, Cassey E.

AU - van Maurik, Lisette M.

AU - Bakker, Amber L.

AU - Bijker, Nina

AU - Verhoeff, Joost J. C.

AU - Slotman, Ben J.

AU - Dinkla, Anna

AU - Verbakel, Wilko F. A. R.

AU - van den Bongard, Desirée H. J. G.

PY - 2026/1/1

Y1 - 2026/1/1

N2 - Background and purpose: Daily differences in breast contour and arm positioning can result in frequent re-positioning and offline re-planning in postoperative breast radiotherapy (RT). Online adaptive radiotherapy (oART) enables daily adaptation of the radiotherapy treatment plan. This study aimed to implement oART in breast and axillary target volumes to eliminate the need for repositioning and replanning. Materials and methods: Patients referred for postoperative partial breast irradiation (PBI) and whole breast irradiation (WBI)/post-mastectomy radiotherapy (PMRT) with or without axillary levels I-II (5x5.2 Gy) or I-IV (15x2.67 Gy) were included. On-couch treatment times were evaluated as well as dosimetry, target volume, acute toxicity, and in-house satisfaction questionnaires. Results: Seventy-nine patients (n = 66 PBI/WBI/PMRT, n = 13 WBI + axillary levels I-II/I-IV) were treated with postoperative RT (465 fractions). On-couch median time ranged from 14.5 (range: 10.1–29.2) minutes for right-sided WBI to 25.8 (range: 22.6–36.8) minutes for left-sided WBI + axillary levels I-II. All adapted treatment plans met the D98% ≥ 95 % coverage criteria for the target PTV. Relative breast CTV volumes for the adapted plan decreased in fraction 1 and increased in fractions 2–5 compared to the CTV volume on the planning CT. Toxicity was mainly grades 0 and 1 and patient satisfaction was good. Conclusion: Implementation of oART was feasible in all breast target volumes with acceptable treatment duration, only mild acute toxicity, favorable patient-reported comfort, and dosimetry that met clinical standards. Future work will focus on the implementation of oART in RT boost indications, and selection of breast cancer patients who will benefit most from oART.

AB - Background and purpose: Daily differences in breast contour and arm positioning can result in frequent re-positioning and offline re-planning in postoperative breast radiotherapy (RT). Online adaptive radiotherapy (oART) enables daily adaptation of the radiotherapy treatment plan. This study aimed to implement oART in breast and axillary target volumes to eliminate the need for repositioning and replanning. Materials and methods: Patients referred for postoperative partial breast irradiation (PBI) and whole breast irradiation (WBI)/post-mastectomy radiotherapy (PMRT) with or without axillary levels I-II (5x5.2 Gy) or I-IV (15x2.67 Gy) were included. On-couch treatment times were evaluated as well as dosimetry, target volume, acute toxicity, and in-house satisfaction questionnaires. Results: Seventy-nine patients (n = 66 PBI/WBI/PMRT, n = 13 WBI + axillary levels I-II/I-IV) were treated with postoperative RT (465 fractions). On-couch median time ranged from 14.5 (range: 10.1–29.2) minutes for right-sided WBI to 25.8 (range: 22.6–36.8) minutes for left-sided WBI + axillary levels I-II. All adapted treatment plans met the D98% ≥ 95 % coverage criteria for the target PTV. Relative breast CTV volumes for the adapted plan decreased in fraction 1 and increased in fractions 2–5 compared to the CTV volume on the planning CT. Toxicity was mainly grades 0 and 1 and patient satisfaction was good. Conclusion: Implementation of oART was feasible in all breast target volumes with acceptable treatment duration, only mild acute toxicity, favorable patient-reported comfort, and dosimetry that met clinical standards. Future work will focus on the implementation of oART in RT boost indications, and selection of breast cancer patients who will benefit most from oART.

UR - https://www.scopus.com/pages/publications/105024923039

U2 - 10.1016/j.ctro.2025.101086

DO - 10.1016/j.ctro.2025.101086

M3 - Article

C2 - 41403709

SN - 2405-6308

VL - 56

JO - Clinical and Translational Radiation Oncology

JF - Clinical and Translational Radiation Oncology

M1 - 101086

ER -

Cone beam computed tomography-guided online adaptive radiation therapy: Clinical implementation in breast and axillary target volumes

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