title: An analysis of intratreatment and intertreatment displacements in pelvic radiotherapy using electronic portal imaging.
abstract: OBJECTIVE
  To evaluate the relative frequency and magnitude of intratreatment and intertreatment displacements in the patient positioning for pelvic radiotherapy using electronic portal imaging.
  
  
  METHODS
  Five hundred ninety-four electronic portal images of seven patients treated with a four-field pelvic technique were evaluated. All patients were treated prone without an immobilization device. Two fields were treated per day, from which an average of two electronic portal images were obtained for each field. No treatment was interrupted or adjusted on the basis of these images. Each image was aligned to the corresponding simulation film to measure the displacements in the mediolateral, craniocaudal, and anteroposterior directions relative to the simulated center. The intertreatment displacement was the displacement measured from the initial image for each daily treated field. For each daily treated field the intratreatment displacement was calculated by subtracting the displacement measured on the initial image from the displacement measured on the final image.
  
  
  RESULTS
  The frequency of the intertreatment displacements exceeding 10 mm was 3%, 16%, and 23% for the mediolateral, craniocaudal, and anteroposterior translations, respectively. There were no intratreatment displacements exceeding 10mm (p < 0.001). The frequency of intertreatment displacements exceeded 5 mm was 40, 52, and 51% for the mediolateral, craniocaudal, and anteroposterior translations, respectively; whereas, the frequency of intratreatment displacements exceeding 5 mm was 1, 5, and 7% for the same translations, respectively (p < 0.001). The standard deviation of the intertreatment displacements was at least three times as great as the standard deviation of the intratreatment displacements for all translations. These deviations were greater than the precision limit of the measurement technique, which is approximately 1mm. Each patient had one direction where systematic error predominated in intertreatment positioning. Random error predominated for intratreatment positioning and for the other two directions in intertreatment positioning.
  
  
  CONCLUSIONS
  During a course of pelvic radiotherapy, the frequency of intertreatment displacements exceeding 5 and 10 mm is significantly greater than the frequency of intratreatment displacements of these magnitudes. Errors in intertreatment positioning are predominantly systematic in one direction for each patient, whereas intratreatment error is predominantly random. Because patients do not move considerably during the daily treatment of a pelvic field, a single electronic portal image per daily field may be considered representative of the treated position.
authors.affiliation: Mallinckrodt Institute of Radiology, Radiation Oncology Center, Washington University Medical Center, St. Louis, MO, 63110, USA.
authors.forename: A
authors.initials: A
authors.lastname: Tinger
authors.forename: J M
authors.initials: JM
authors.lastname: Michalski
authors.forename: W R
authors.initials: WR
authors.lastname: Bosch
authors.forename: R K
authors.initials: RK
authors.lastname: Valicenti
authors.forename: D A
authors.initials: DA
authors.lastname: Low
authors.forename: R J
authors.initials: RJ
authors.lastname: Myerson
mesh_terms: D000230:Adenocarcinoma / Q000532:radiotherapy*; D005069:Evaluation Studies as Topic; D006801:Humans; D007091:Image Processing, Computer-Assisted / Q000379:methods; D010388:Pelvis / Q000528:radiation effects; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D012004:Rectal Neoplasms / Q000532:radiotherapy*