title: Surgical clips for position verification and correction of non-rigid breast tissue in simultaneously integrated boost (SIB) treatments.
abstract: OBJECTIVE
  The aim of this study is to investigate whether surgical clips in the lumpectomy cavity are representative for position verification of both the tumour bed and the whole breast in simultaneously integrated boost (SIB) treatments.
  
  
  METHODS
  For a group of 30 patients treated with a SIB technique, kV and MV planar images were acquired throughout the course of the fractionated treatment. The 3D set-up error for the tumour bed was derived by matching the surgical clips (3-8 per patient) in two almost orthogonal planar kV images. By projecting the 3D set-up error derived from the planar kV images to the (u, v)-plane of the tangential beams, the correlation with the 2D set-up error for the whole breast, derived from the MV EPID images, was determined. The stability of relative clip positions during the fractionated treatment was investigated. In addition, for a subgroup of 15 patients, the impact of breathing was determined from fluoroscopic movies acquired at the linac.
  
  
  RESULTS
  The clip configurations were stable over the course of radiotherapy, showing an inter-fraction variation (1 SD) of 0.5mm on average. Between the start and the end of the treatment, the mean distance between the clips and their center of mass was reduced by 0.9 mm. A decrease larger than 2mm was observed in eight patients (17 clips). The top-top excursion of the clips due to breathing was generally less than 2.5mm in all directions. The population averages of the difference (+/-1 SD) between kV and MV matches in the (u, v)-plane were 0.2+/-1.8mm and 0.9+/-1.5mm, respectively. In 30% of the patients, time trends larger than 3mm were present over the course of the treatment in either or in both kV and MV match results. Application of the NAL protocol based on the clips reduced the population mean systematic error to less than 2mm in all directions, both for the tumour bed and the whole breast. Due to the observed time trends, these systematic errors can be further reduced to about 1mm by using an eNAL protocol instead.
  
  
  CONCLUSIONS
  The relative positions of implanted surgical clips in the lumpectomy cavity after breast-conserving surgery remain stable during the course of radiotherapy treatment. Application of a NAL or eNAL set-up correction protocol based on surgical clips allows for adequate treatment of both the tumour bed and the whole breast with tight CTV-PTV margins.
authors.affiliation: Department of Radiation Oncology, Erasmus MC - Daniel den Hoed Cancer Center, Rotterdam, The Netherlands. j.penninkhof@erasmusmc.nl
authors.forename: Joan
authors.initials: J
authors.lastname: Penninkhof
authors.forename: Sandra
authors.initials: S
authors.lastname: Quint
authors.forename: Hans de
authors.initials: Hd
authors.lastname: Boer
authors.forename: Jan Willem
authors.initials: JW
authors.lastname: Mens
authors.forename: Ben
authors.initials: B
authors.lastname: Heijmen
authors.forename: Maarten
authors.initials: M
authors.lastname: Dirkx
mesh_terms: D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000532:radiotherapy* / Q000601:surgery; D003131:Combined Modality Therapy; D019583:Dose Fractionation, Radiation; D005260:Female; D006801:Humans; D016014:Linear Models; D015412:Mastectomy, Segmental; D009038:Motion; D011857:Radiographic Image Interpretation, Computer-Assisted; D015641:Radiography, Interventional; D013525:Surgical Instruments; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome