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With the introduction of new beasts in the zoo we call our current machine park we might be in the beginning of an Online Adaptive Radiotherapy (oART) era. There are oART workflows we can use today and others we should avoid. And it’s definitively not a one fits all situation. With real world examples and discussion points I’ll try to address some of the issues and solutions for current MR- and CBCT guided oART.

The basic idea behind oART is simple. The patient change from fraction to fraction and thus the geometry of our irradiating beams should change accordingly. The basic principle behind treating with oART is likewise simple. We monitor the changes in the patient, define target volumes and organs at risk, and adapt the original treatment plan to fit the current situation. For (most) current oART the changes we adapt to are anatomical changes. Some of these changes can be monitored utilizing MR- and CBCT imaging available on dedicated treatment units. Workflows, pitfalls, and problems and solutions for oART utilizing these treatment units will be the focus of this talk. As always, the simple becomes more complicated when it meets the reality of real patients, limited image quality, time constraints, intra-fractional changes, system limitations, and knowledge gabs.