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@ARTICLE{Gambetta:307518,
      author       = {V. Gambetta and K. Stützer and C. Richter$^*$},
      title        = {{C}urrent status and upcoming developments for online
                      adaptive proton therapy enabling a closed feedback loop for
                      near real-time adaptation.},
      journal      = {Frontiers in oncology},
      volume       = {15},
      issn         = {2234-943X},
      address      = {Lausanne},
      publisher    = {Frontiers Media},
      reportid     = {DKFZ-2026-00023},
      pages        = {1660605},
      year         = {2025},
      abstract     = {Proton therapy (PT) has the potential to deliver conformal
                      doses to the tumor while sparing normal tissue, but is
                      highly susceptible to treatment uncertainties. The
                      occurrence of anatomical changes during PT treatments has a
                      major impact on the delivered dose, often necessitating plan
                      adaptations that are typically performed offline and require
                      a few days before the adapted plan is ready. In order to
                      react promptly to detected anatomical changes, online
                      adaptive proton therapy (OAPT) has been proposed with the
                      goal of adapting the plan while the patient is on the
                      treatment couch. First OAPT workflows for daily plan
                      adaptation that are effective against interfractional
                      anatomical variations have reached clinical application.
                      However, even faster OAPT workflows are needed to cope with
                      faster anatomical changes. Near real-time adaptive PT (NAPT)
                      relying on online in vivo treatment verification can be a
                      potential solution for many tumor entities (e.g.,
                      thoraco-abdominal tumors), which would greatly benefit from
                      the conformality of PT, but are presently challenging to
                      treat with proton beams due to the influence of
                      intrafractional variations. In addition, NAPT offers the
                      opportunity to achieve the long-awaited closed PT feedback
                      loop. In this paper we review the required tasks and
                      necessary components in an OAPT workflow for the application
                      of near real-time adaptation, proceeding sequentially from
                      volumetric imaging for online plan adaptation up to online
                      verification during delivery. Available technology and
                      upcoming developments are discussed. Several aspects
                      regarding regulatory approval, cost-benefit related issues
                      and additional beyond-the-loop tasks are also addressed.},
      subtyp        = {Review Article},
      keywords     = {cancer (Other) / near real-time adaptation (Other) / online
                      QA (Other) / online adaptive proton therapy (Other) / online
                      plan optimization (Other) / proton therapy (Other) /
                      treatment verification (Other) / volumetric imaging (Other)},
      cin          = {DD01},
      ddc          = {610},
      cid          = {I:(DE-He78)DD01-20160331},
      pnm          = {899 - ohne Topic (POF4-899)},
      pid          = {G:(DE-HGF)POF4-899},
      typ          = {PUB:(DE-HGF)16},
      pubmed       = {pmid:41479791},
      pmc          = {pmc:PMC12754733},
      doi          = {10.3389/fonc.2025.1660605},
      url          = {https://inrepo02.dkfz.de/record/307518},
}