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Time‐consuming manual methods have been required to register cone‐beam computed tomography ( CBCT ) images with plans in the Pinnacle 3  treatment planning system in order to replicate delivered treatments for adaptive radiotherapy. These methods rely on fiducial marker ( FM ) placement during  CBCT  acquisition or the image mid‐point to localise the image isocentre. A quality assurance study was conducted to validate an automated  CBCT ‐plan registration method utilising the Digital Imaging and Communications in Medicine ( DICOM ) Structure Set ( RS ) and Spatial Registration ( RE ) files created during online image‐guided radiotherapy ( IGRT ).    Methods   CBCT s of a phantom were acquired with  FM s and predetermined setup errors using various online  IGRT  workflows. The  CBCT s,  DICOM RS  and  RE  files were imported into Pinnacle 3  plans of the phantom and the resulting automated  CBCT ‐plan registrations were compared to existing manual methods. A clinical protocol for the automated method was subsequently developed and tested retrospectively using  CBCT s and plans for six bladder patients.    Results  The automated  CBCT ‐plan registration method was successfully applied to thirty‐four phantom  CBCT  images acquired with an online 0 mm action level workflow. Ten  CBCT s acquired with other  IGRT  workflows required manual workarounds. This was addressed during the development and testing of the clinical protocol using twenty‐eight patient  CBCT s. The automated  CBCT ‐plan registrations were instantaneous, replicating delivered treatments in Pinnacle 3  with errors of ±0.5 mm. These errors were comparable to mid‐point‐dependant manual registrations but superior to  FM ‐dependant manual registrations.    Conclusion  The automated  CBCT ‐plan registration method quickly and reliably replicates delivered treatments in Pinnacle 3  for adaptive radiotherapy.

Automated replication of cone beam CT ‐guided treatments in the Pinnacle 3 treatment planning system for adaptive radiotherapy