End-to-end testing of an online adaptive radiotherapy workflow for liver tumors using a dynamic Thoraco-abdominal anthropomorphic phantom.

Objective.Adaptive radiotherapy (ART) requires robust end-to-end (E2E) testing tools capable of reproducing organ deformation, physiological motion, and multimodal imaging properties. TheToraco-abdominalAnthropomorphic Phantom withMotion forAdaptiveRadiotherapy (TAM-ARa) is a dynamic anthropomorphic phantom developed to support the design, validation, and quality assurance of online ART workflows.Approach.The phantom was constructed with anatomically realistic bone, lung, and abdominal organ models fabricated from tissue equivalent materials. Modular components allowed simulation of interfractional and intrafractional anatomical variations, including ventilator driven respiratory motion, abdominal deformation, and variable gastric filling. CT, CBCT, and 3T MRI scans were acquired to assess imaging performance. Two E2E tests of an online adaptive intensity-modulated radiotherapy (IMRT) workflow for liver tumors were performed on a Varian Ethos (ETHOS, Varian, USA) system. Multiple deformation scenarios were investigated, including a static reference configuration, two abdominal and one thoracic deformation for ionization chamber (IC) dosimetry, and a static plus abdominal deformation scenarios for radiochromic film dosimetry.Main results.The TAM-ARa phantom demonstrated realistic radiological characteristics, with CT Hounsfield units and MRI relaxation times closely matching reportedin vivovalues. The modular architecture allowed reproducible and controlled abdominal deformations, while setup and dosimeter placement were completed within minutes. In E2E tests for adaptive IMRT of liver tumors, excellent agreement was achieved between measured and planned dose distributions after the treatment plan was adapted. IC E2E measurements showed that online adaptation consistently restored accurate dose delivery under deformation, reducing deviations to below 3%. Independent film measurements confirmed sub-millimeter geometric accuracy and full planning target volume coverage after adaptation, demonstrating effective compensation of deformation-induced errors.Significance.The TAM-ARa phantom provides a versatile and reproducible platform for multimodal E2E testing and validation of online ART workflows. Employing its realistic anatomical design, modular structure, and motion capabilities, TAM-ARa was successfully applied for E2E tests to validate a workflow for adaptive IMRT of liver tumors.