{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T16:04:20Z","timestamp":1784217860617,"version":"3.55.0"},"reference-count":57,"publisher":"Wiley","issue":"7","license":[{"start":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T00:00:00Z","timestamp":1783382400000},"content-version":"vor","delay-in-days":6,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T00:00:00Z","timestamp":1782864000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["aapm.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J Applied Clin Med Phys"],"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>In the online adaptive platform, a linear Boltzmann\u2010transport\u2010equation\u2010solver (LBTE) as calculation algorithm is implemented for dose optimization. This class\u2010C\u2010optimizer is known to counteract the dose decrease at boundaries of small fields due to electronic disequilibrium by increasing the fluence to achieve the goals of dose homogeneity within the PTV.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>To analyze the dosimetric sensitivity of adaptive treatment plans for prostate cancer to intrafractional anatomic changes in the presence of rectal air using a CBCT\u2010based adaptive platform.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      In the first part of the study planning CT scans (CT\n                      <jats:sub>plan<\/jats:sub>\n                      ) from eight patients treated with an air\u2010filled endorectal balloon and two patients presenting larger rectal air pockets were included in a simulation study. The dataset was used to assess the sensitivity of LBTE\u2010optimized treatment plans to intrafractional density variations and to changes in the overlap between the planning target volume (PTV) and an air cavity (PTV\u2229Air structure). Density changes resulting from anatomical shifts were simulated using water overrides (WOR) in defined shift regions within the PTV\u2229Air structure. These shift regions were created by dorsally expanding the clinical target volume (CTV) by margins of 2\u00a0mm or 5\u00a0mm. Additionally, a WOR of the entire rectum was applied. For each WOR scenario, D\n                      <jats:sub>max<\/jats:sub>\n                      , D\n                      <jats:sub>1<\/jats:sub>\n                      and D\n                      <jats:sub>1cc<\/jats:sub>\n                      values were recorded within the fixed PTV\u2229Air structure and within the rectal wall, which was shifted according to the applied margin. A mixed linear model was built to describe dosimetric characteristics in dependence of the WOR scenario. Additionally, intrafractional variations of D\n                      <jats:sub>max<\/jats:sub>\n                      within the PTV were assessed in 101 dose fractions from 15 patients who were treated with a rectal balloon and underwent online adaptive radiotherapy. All doses were normalized by the prescribed dose.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      WOR within PTV\u2229Air\u2010structure overlap resulted in increases of the analyzed dosimetric characteristics. D\n                      <jats:sub>1cc<\/jats:sub>\n                      increased with WOR within shift margins of 2 and 5\u00a0mm and within the entire rectal cavity by 2.2%\u00a0\u00b1\u00a00.7%, 5.5%\u00a0\u00b1\u00a00.7%, and 8.7%\u00a0\u00b1\u00a01.0%, respectively (\n                      <jats:italic>p<\/jats:italic>\n                      \u00a0&lt;\u00a00.0001,\n                      <jats:italic>F<\/jats:italic>\n                      \u2010test). The corresponding dose increases within the rectal wall were slightly smaller, with D\n                      <jats:sub>1cc<\/jats:sub>\n                      \u200b increases of 1.4%\u00a0\u00b1\u00a00.6%, 1.7%\u00a0\u00b1\u00a00.9%, and 5.0%\u00a0\u00b1\u00a00.5%. Sensitivity to WOR in the PTV\u2229Air using a 5\u00a0mm shift margin was markedly lower when the same treatment plans were recalculated with AAA compared with LBTE (\n                      <jats:italic>p\u00a0<\/jats:italic>\n                      =\u00a00.0020, signed\u2010rank test). On average, AAA detected only 43%\u00a0\u00b1\u00a012% of the WOR effect predicted by LBTE. For prostate cancer patients treated with a rectal balloon, D\n                      <jats:sub>max<\/jats:sub>\n                      , D\n                      <jats:sub>1<\/jats:sub>\n                      and D\n                      <jats:sub>1cc<\/jats:sub>\n                      changes in LBTE\u2010optimized plans showed 90% confidence intervals of [\u22120.05\u20130.05] due to intrafractional motion, suggesting that posterior tissue shifts of 5 mm or less do not have a clinically relevant impact.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>PTV\u2229Air larger than 5\u00a0mm led to LBTE\u2010optimized treatment plans, that are sensitive to anatomic soft tissue shifts larger than 5\u00a0mm in posterior direction with respect to dose homogeneity. PTV\u2229Air\u2010overlaps up to\u00a05\u00a0mm led to LBTE\u2010optimized treatment plans, that showed only minor sensitivities to anatomic soft tissue shifts of 2\u20135\u00a0mm in posterior direction with respect to dose homogeneity. During online adaptive radiotherapy, the presence of rectal air pockets or an air\u2010filled rectal balloon did not result in clinically relevant dose increases, provided that intrafractional motion\u2013induced soft tissue shifts remained within 5\u00a0mm in the posterior direction.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/acm2.70675","type":"journal-article","created":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T04:42:29Z","timestamp":1783485749000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Effects of air on the dosimetric robustness of treatment plans for prostate cancer in the presence of intrafractional, anatomical changes during online adaptive radiotherapy"],"prefix":"10.1002","volume":"27","author":[{"given":"Nika","family":"Guberina","sequence":"first","affiliation":[{"name":"Department of Radiotherapy West German Cancer Center University Hospital Essen University of Duisburg 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