Impact evaluation of intra-fractional variation on online adaptive radiotherapy for postoperative cervical and endometrial cancer

doi:10.5306/wjco.v16.i12.111601

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Dec 24, 2025 (publication date) through Dec 29, 2025

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World Journal of Clinical Oncology

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World J Clin Oncol. Dec 24, 2025; 16(12): 111601
Published online Dec 24, 2025. doi: 10.5306/wjco.v16.i12.111601

Impact evaluation of intra-fractional variation on online adaptive radiotherapy for postoperative cervical and endometrial cancer

Guang-Yu Wang, Yi-Ning Chen, Yu-Liang Sun, Bing Zhou, Fu-Quan Zhang, Jun-Fang Yan, Ke Hu

Guang-Yu Wang, Yi-Ning Chen, Yu-Liang Sun, Bing Zhou, Fu-Quan Zhang, Jun-Fang Yan, Ke Hu, Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China

Co-first authors: Guang-Yu Wang and Yi-Ning Chen.

Co-corresponding authors: Jun-Fang Yan and Ke Hu.

Author contributions: Wang GY and Chen YN contributed equally to this work as co-first authors; Yan JF and Hu K contributed equally to this work as co-corresponding authors; Wang GY and Chen YN collected and analyzed the data and wrote the manuscript; Sun YL and Zhou B participated in data acquisition and provided critical input for data interpretation; Zhang FQ, Yan JF and Hu K designed and supervised the study, provided expertise in analysis of the data, and revised the manuscript; all authors have contributed to the manuscript and approved the submitted version.

Supported by the National Key R&D Program of China, No. 2022YFC2407100 and No. 2022YFC2407101; and the National High Level Hospital Clinical Research Funding, No. 2022-PUMCH-B-127.

Institutional review board statement: This study was reviewed and approved by the Institutional Review Board of Peking Union Medical College Hospital (Approval No. K2416).

Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.

Conflict-of-interest statement: The authors declare that they have no conflicts of interest to disclose.

STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.

Data sharing statement: No additional data are available.

Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Corresponding author: Jun-Fang Yan, MD, Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing 100730, China. yanjunfang@pumch.cn

Received: July 7, 2025
Revised: August 30, 2025
Accepted: November 11, 2025
Published online: December 24, 2025
Processing time: 172 Days and 17.7 Hours

Abstract

BACKGROUND

Online adaptive radiotherapy (oART) has demonstrated improved target volume coverage and enhanced sparing of surrounding pelvic organs through daily re-optimization based on pretreatment imaging. Recently, iterative cone-beam computed tomography (iCBCT) has been integrated into oART workflows, facilitating precise daily adaptation. However, the dosimetric consequences of intra-fractional variations for clinical target volume (CTV) and organs at risk (OARs) remain insufficiently characterized.

AIM

To investigate intra-fractional CTV and OARs variation and their impact on iCBCT guided daily oART for postoperative cervical and endometrial cancer.

METHODS

Seventeen patients treated with daily postoperative iCBCT guided oART with rigorous bladder and rectal preparation protocols were enrolled. CTV and OARs were contoured on pre- and post-treatment iCBCT scans. The average surface distance (ASD), dice similarity coefficient (DSC), and 95% Hausdorff distance (HD) were utilized to evaluate the difference between pre- and post-treatment structures. Dosimetric outcomes for the pretreatment target volumes and OARs were recalculated using posttreatment contours to assess the impact of intra-fractional variation.

RESULTS

A total of 434 treatment fractions were analyzed, with an average interval time of 22 minutes between two iCBCT scans. Minimal variations were observed in the bladder, rectum, and CTV both pre- and post-treatment, with DSC exceeding 0.8. The vaginal CTV exhibited centroid deviations of 0.46 mm anteriorly, 0.11 mm laterally, and 0.58 mm superiorly, along with ASD of 1.69 mm and 95% HD of 6.42 mm. Weak correlations were observed between vaginal CTV posterior-anterior centroid deviations and rectal superior-inferior deviations (P = 0.017). Minimal dosimetric differences were observed pre- and post-treatment, with V_100% for the adapted plan of nodal CTV being 99.94% vs 99.08% and vaginal CTV being 99.97% vs 98.66%.

CONCLUSION

Daily iCBCT-guided oART with strict bladder and rectal preparation effectively compensates for intra-fractional variations, maintaining CTV coverage and OAR sparing across all treatment fractions.

Keywords: Cone-beam computed tomography; Online adaptive radiotherapy; Intra-fractional variation; Endometrial cancer; Cervical cancer

Core Tip: By analyzing 434 treatment fractions with rigorous bladder and rectal preparation protocols, the study demonstrated that intra-fractional motion of clinical target volumes and organs at risk was minimal and had negligible impact on dosimetric outcomes of postoperative cervical and endometrial cancer. These findings provide robust clinical evidence supporting the reliability and precision of iterative cone-beam computed tomography-guided online adaptive radiotherapy in the postoperative pelvic setting.