Background/Objectives:Cone-beam computed tomography (CBCT)-guided online adaptive radiotherapy (oART) represents a significant advancement in radiation oncology, enabling on-couch plan adaptation to account for daily anatomical changes. While this automation improves precision and workflow efficiency, it also introduces new failure modes (FMs) and workflow irregularities. This study aimed to systematically evaluate the clinical and technical challenges associated with CBCT-guided oART implementation.Methods:We retrospectively analyzed over 1000 CBCT-guided oART sessions for pelvic malignancies performed at our institution. A multidisciplinary team conducted a comprehensive review to identify and classify FMs, followed by root cause analysis (RCA) to evaluate their impact on treatment safety, efficacy, and workflow robustness.Results:In addition to session-terminating FMs, we identified recurring failure modes across three major domains: (1) system-driven issues, such as rigid target localization and software-driven irregularities; (2) patient-driven challenges, including interfractional and intrafractional anatomical variations; and (3) treatment planning and execution failures, including excessive dose hotspots from field-of-view limitations. The system’s closed-loop automation, while streamlining processes, introduced rigid constraints in plan adaptation and fallback plan execution, occasionally leading to unintended dose discrepancies.Conclusions:This study provides a comprehensive clinical practice-based evaluation of CBCT-guided oART, highlighting system-specific failure modes and their implications. Addressing these challenges requires structured quality assurance processes, multidisciplinary collaboration, and continuous workflow refinement. Our findings contribute to the development of safer and more robust adaptive radiotherapy platforms and clinical workflows.
**背景/目的：** 锥形束计算机断层扫描（CBCT）引导的在线自适应放射治疗（oART）是放射肿瘤学领域的重要进展，可在治疗床上根据每日解剖结构变化实时调整治疗计划。尽管该自动化技术提升了治疗精度和工作流程效率，但也引入了新的故障模式（FMs）及工作流程异常。本研究旨在系统评估CBCT引导oART实施过程中面临的临床与技术挑战。 **方法：** 我们回顾性分析了本机构实施的1000余例盆腔恶性肿瘤CBCT引导oART治疗过程。通过多学科团队全面审查，识别并分类故障模式，随后进行根本原因分析（RCA），评估其对治疗安全性、疗效及工作流程稳定性的影响。 **结果：** 除导致治疗中断的故障模式外，我们识别出三大类反复出现的故障模式：（1）系统驱动问题，如刚性靶区定位及软件引发的异常；（2）患者相关挑战，包括分次间及分次内的解剖结构变化；（3）治疗计划与执行故障，如因扫描视野限制导致的剂量热点过高。该系统的闭环自动化虽优化了流程，却在计划调整和备用计划执行中引入了刚性限制，偶发导致非预期的剂量偏差。 **结论：** 本研究基于临床实践对CBCT引导oART进行了全面评估，揭示了系统特异性故障模式及其影响。应对这些挑战需建立结构化质量保证流程、加强多学科协作并持续优化工作流程。本研究结果为开发更安全、更稳定的自适应放射治疗平台及临床工作流程提供了重要参考。
肿瘤(癌症)患者之家