Determination of the optimal matching position for setup images and minimal setup margins in adjuvant radiotherapy of breast and lymph nodes treated in voluntary deep inhalation breath-hold

Background Adjuvant radiotherapy (RT) of left-sided breast cancer is increasingly performed in voluntary deep inspiration breath-hold (vDIBH). The aim of this study was to estimate the reproducibility of breath-hold level (BHL) and to find optimal bony landmarks for matching of orthogonal setup images to minimise setup margins. Methods 1067 sets of images with an orthogonal setup and tangential field from 67 patients were retrospectively analysed. Residual position errors were determined in the tangential treatment field images for different matches of the setup images. Variation of patient posture and BHL were analysed for position errors of the vertebrae, clavicula, ribs and sternum in the setup and tangential field images. The BHL was controlled with a Varian RPM® system. Setup margins were calculated using the van Herk’s formula. Patients who underwent lymph node irradiation were also investigated. Results For the breast alone, the midway compromise of the ribs and sternum was the best general choice for matching of the setup images. The required margins were 6.5 mm and 5.3 mm in superior-inferior (SI) and lateral/anterior-posterior (LAT/AP) directions, respectively. With the individually optimised image matching position also including the vertebrae, slightly smaller margins of 6.0 mm and 4.8 mm were achieved, respectively. With the individually optimised match, margins of 7.5 mm and 10.8 mm should be used in LAT and SI directions, respectively, for the lymph node regions. These margins were considered too large. The reproducibility of the BHL was within 5 mm in the AP direction for 75% of patients. Conclusions The smallest setup margins were obtained when the matching position of the setup images was individually optimised for each patient. Optimal match for the breast alone is not optimal for the lymph node region, and, therefore, a threshold of 5 mm was introduced for residual position errors of the sternum, upper vertebrae, clavicula and chest wall to retain minimal setup margins of 5 mm. Because random interfraction variation in patient posture was large, we recommend daily online image guidance. The BHL should be verified with image guidance.BioMed Central open acces

Improving the reproducibility of voluntary deep inspiration breath hold technique during adjuvant left-sided breast cancer radiotherapy

<p><b>Background</b>: Adjuvant radiotherapy (RT) of left-sided breast cancer (LSBC) with voluntary deep inspiration breath hold (vDIBH) technique reduces the cardiac dose. In this study, the effect of marker block position and the efficacy of breath hold level (BHL) correction based on lateral kV setup images are evaluated to improve the daily reproducibility. <b>Material and methods</b>: A total of 148 consecutive LSBC patients treated with vDIBH RT were included in this study. The real-time position management (RPM) marker block was placed on the abdominal wall in 63 patients (group A) and on the sternum in 85 patients (group S). Acquired 900 (group A) + 1040 (group S) orthogonal image pairs were retrospectively analyzed. The actual BHL was determined from the lateral kV images. The height of the BHL gating window in RPM was corrected if errors of the actual BHL exceeded 4 mm. Setup margins were calculated for the chest wall and for bony surrogates of the lymph node regions. <b>Results</b>: The sternal marker block reduced the random residual errors in the actual BHL (p < 0.05). The BHL correction was required for 26/63 patients in group A and for 26/85 patients in group S. Correction of the BHL window significantly reduced both the systematic and the random residual error in both groups. In patients with lymph node irradiation, the effect of both marker placement and BHL window correction was significant in the superior-inferior direction. Correction of the BHL reduced the mean cardiac dose by 0.5 Gy (p < 0.01) in group A and 0.6 Gy (p < 0.05) in group S. <b>Conclusions</b>: Reproducibility of the BHL can be improved by placing the marker block on the sternum and correcting the height of the BHL window based on lateral kV setup images. Acquisition of lateral kV images in the first 3 fractions and once a week during RT is recommended.</p