title: Clinical evaluation of interfractional variations for whole breast radiotherapy using 3-dimensional surface imaging.
abstract: OBJECTIVE
  To evaluate the impact of 3-dimensional (3D) surface imaging on daily patient setup for breast radiotherapy.
  
  
  METHODS
  Fifty patients undergoing treatment for whole breast radiotherapy were setup daily using an AlignRT system (VisionRT, London, UK) for 3D surface-based alignment. Daily alignments were performed against a reference surface topogram and shifts from skin marks were recorded daily. This investigation evaluated the following: (1) the performance of the surface-based imaging system for daily breast alignment; (2) the absolute displacements between setup with skin marks and setup with the surface-based imaging system; and (3) the dosimetric effect of daily alignments with skin marks versus surface-based alignments.
  
  
  RESULTS
  Displacements from 1258 treatment fractions were analyzed. Sixty percent of those fractions (749) were reviewed against MV portal imaging in order to assess the performance of the AlignRT system. Daily setup errors were given as absolute displacements, comparing setup marks against shifts determined using the surface-based imaging system. Averaged over all patients, the mean displacements were 4.1 ± 2.6 mm, 2.7 ± 1.4 mm, and 2.6 ± 1.2 mm in the anteroposterior (AP), superoinferior (S/I), and left-right (L/R) directions, respectively. Furthermore, the standard deviation of the random error (σ) was 3.2 mm, 2.2 mm, and 2.2 mm in the A/P, S/I, and L/R directions, respectively.
  
  
  CONCLUSIONS
  Daily alignment with 3D surface imaging was found to be valuable for reducing setup errors when comparing with patient alignment from skin marks. The result of the surface-based alignments specifically showed that alignment with skin marks was noticeably poor in the anteroposterior directions. The overall dosimetric effect of the interfractional variations was small, but these variations showed a potential for increased dose deposition to both the heart and lung tissues. Although these interfractional variations would not negatively affect the quality of patient care for whole breast radiotherapy, it may require an increase in PTV margin, especially in cases of partial breast irradiation.
authors.affiliation: Department of Radiation Oncology, MD Anderson Cancer Center Orlando, Orlando, Florida. Electronic address: Amish.Shah@orlandohealth.com.
authors.forename: Amish P
authors.initials: AP
authors.lastname: Shah
authors.affiliation: Department of Radiation Oncology, MD Anderson Cancer Center Orlando, Orlando, Florida.
authors.forename: Tomas
authors.initials: T
authors.lastname: Dvorak
authors.affiliation: Department of Radiation Oncology, MD Anderson Cancer Center Orlando, Orlando, Florida.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Curry
authors.affiliation: Department of Radiation Oncology, MD Anderson Cancer Center Orlando, Orlando, Florida.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Buchholz
authors.affiliation: Department of Radiation Oncology, MD Anderson Cancer Center Orlando, Orlando, Florida.
authors.forename: Sanford L
authors.initials: SL
authors.lastname: Meeks