First implementation of full-workflow automation in radiotherapy: the All-in-One solution on rectal cancer

The aim of this work is to describe the technical characteristics of an AI-powered radiotherapy workflow that enables full-process automation (All-in-One), evaluate its performance implemented for on-couch initial treatment of rectal cancer, and provide insight into the behavior of full-workflow automation in the specialty of radiotherapy. The All-in-One workflow was developed based on a CT-integrated linear accelerator. It incorporates routine radiotherapy procedures from simulation, autosegmentation, autoplanning, image guidance, beam delivery, and in vivo quality assurance (QA) into one scheme, with critical decision points involved, while the patient is on the treatment couch during the whole process. For the enrolled ten patients with rectal cancer, minor modifications of the autosegmented target volumes were required, and the Dice similarity coefficient and 95% Hausdorff distance before and after modifications were 0.892{\pm}0.061 and 18.2{\pm}13.0 mm, respectively. The autosegmented normal tissues and automatic plans were clinically acceptable without any modifications or reoptimization. The pretreatment IGRT corrections were within 2 mm in all directions, and the EPID-based in vivo QA showed a {\gamma} passing rate better than 97{\%} (3{\%}/3 mm/10{\%} threshold). The duration of the whole process was 23.2{\pm}3.5 minutes, depending mostly on the time required for manual modification and plan evaluation. The All-in-One workflow enables full automation of the entire radiotherapy process by seamlessly integrating multiple routine procedures. The one-stop solution shortens the time scale it takes to ready the first treatment from days to minutes, significantly improving the patient experience and the efficiency of the workflow, and shows potential to facilitate the clinical application of online adaptive replanning.