title: Clinical implementation of kilovoltage cone beam CT for the verification of sequential and integrated photon boost treatments for breast cancer patients.
abstract: OBJECTIVE
  The objective of this study was to formulate a practical method for the use of cone beam CT (CBCT) for the verification of sequential and integrated tumour bed boosts for early breast cancer patients.
  
  
  METHODS
  Partial arc scan geometries were assessed on a treatment unit. Imaging dose measurements on an Elekta Synergy CBCT system were made in a CT dose phantom for scan parameters 100 kV, 25 mA and 40 ms with an S20 collimator. The protocol was used to verify the setup of a cohort of 38 patients, all of whom had surgical clips inserted in the tumour bed. Setup errors with and without an extended no action level (eNAL) protocol were calculated.
  
  
  RESULTS
  Arcs from 260° to 85° (left breast) and 185° to 15° (right breast) were found sufficient to image fiducial markers and anatomy whilst accounting for the physical limits of the equipment. A single treatment and imaging isocentre was found by applying simple constraints: isocentre <8 cm from midline and isocentre-couch distance <30 cm. Contralateral breast doses were ∼2 mGy per scan (right breast) and ∼12 mGy (left breast). Both mean population systematic error and mean population random error were 3 mm prior to correction. The systematic error reduced to 1.5 mm using an eNAL correction protocol, implying that a 5-mm setup margin could be achieved.
  
  
  CONCLUSIONS
  An image-guided verification protocol using CBCT for breast cancer boost plans was implemented successfully. Setup errors were reduced with an acceptable imaging dose to the contralateral breast.
authors.affiliation: Joint Department of Physics, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, UK. Ellen.Donovan@icr.ac.uk
authors.forename: E M
authors.initials: EM
authors.lastname: Donovan
authors.forename: I
authors.initials: I
authors.lastname: Castellano
authors.forename: S
authors.initials: S
authors.lastname: Eagle
authors.forename: E
authors.initials: E
authors.lastname: Harris
mesh_terms: D001940:Breast / Q000473:pathology; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000532:radiotherapy; D054893:Cone-Beam Computed Tomography / Q000379:methods; D005260:Female; D057918:Fiducial Markers; D006801:Humans; D019047:Phantoms, Imaging; D017785:Photons / Q000627:therapeutic use; D011879:Radiotherapy Dosage; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods*; D013525:Surgical Instruments