A traffic light protocol workflow for image-guided adaptive radiotherapy in lung cancer patients

Background and purpose: Image-guided radiotherapy using cone beam-CT (CBCT) images is used to eval-uate patient anatomy and positioning before radiotherapy. In this study we analyzed and optimized a traffic light protocol (TLP) used in lung cancer patients to identify patients requiring treatment adapta-tion. Materials and methods: First, CBCT review requests of 243 lung cancer patients were retrospectively ana-lyzed and divided into 6 pre-defined categories. Frequencies and follow-up actions were scored. Based on these results, the TLP was optimized and evaluated in the same way on 230 patients treated in 2018. Results: In the retrospective study, a total of 543 CBCT review requests were created during treatment in 193/243 patients due to changed anatomy of lung (24%), change of tumor volume (24%), review of match (18%), shift of the mediastinum (15%), shift of tumor (15%) and other (4%). The majority of requests (474, 87%) did not require further action. In 6% an adjustment of the match criteria sufficed; in 7% treatment plan adaptation was required. Plan adaptation was frequently seen in the categories changed anatomy of lung, change of tumor volume and shift of tumor outside the PTV. Shift of mediastinum outside PRV and shift of GTV outside CTV (but inside PTV) never required plan adaptation and were omitted to opti-mize the TLP, which reduced the CBCT review requests by 23%.Conclusions: The original TLP selected patients that required a treatment adaptation, but with a high false positive rate. The optimized TLP reduced the amount of CBCT review requests, while still correctly iden-tifying patients requiring adaptation.(c) 2022 The Authors. Published by Elsevier B.V. Radiotherapy and Oncology 175 (2022) 152-158 This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).