AN AUTOMATED END-TO-END WORKFLOW ENABLING ONLINE ADAPTIVE UPRIGHT PROTON THERAPY FOR HEAD AND NECK AND BRAIN MALIGNANCIES

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Background and Aims: Online adaptive proton therapy enables re-optimization of treatment plans on the day of treatment to account for inter-fraction anatomical changes such as tumor displacement and organ motion.In upright image-guided proton therapy systems equipped with in-room vertical CT, high-quality daily imaging supports this approach.However, the adaptive process is time-critical and typically limited to 15-30 minutes.This work aimed to develop a fully automated, scripted workflow to minimize manual intervention and reduce overall adaptive cycle time for upright proton therapy.Methods: An end-to-end automated workflow was developed for the P-Cure upright proton therapy system with integrated diagnosticquality vertical CT (Philips Brilliance Big Bore).Automation was implemented in RayStation v2025SP1 using the Python scripting interface.Following daily CT acquisition, the script performs rigid and deformable registrations between planning and daily CTs, clears and recreates relevant regions of interest (ROIs), propagates targets and organs-at-risk (OARs), and generates a valid external contour within the limited field of view.The workflow includes automatic frame-of-reference handling, image alignment, creation of field-ofview and external ROIs, hole removal, and air overrides beyond the imaging range.A hybrid deformable registration is set as default for dose deformation, and all relevant ROIs are mapped to the daily CT.Two adaptive plans are then generated automatically: (1) a recomputed plan using the original beamset and (2) a fully re-optimized plan based on current anatomy.The physician reviews propagated contours and dose distributions before plan selection and delivery.Results: The automated workflow in RayStation executed all adaptive steps without user intervention, including deformable registration, contour propagation, and plan generation.The computation time was under seven minutes, and the entire adaptive cycle, including physician review, was finished in 20 minutes.Conclusions: A fully scripted workflow for online adaptive upright proton therapy was established, enabling rapid plan adaptation and minimizing manual workload.Future work will validate the process in clinical pilot cases and integrate automated plan evaluation and dose accumulation for routine clinical use.

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