title: Quantifying intra- and inter-fractional motion in breast radiotherapy.
abstract: BACKGROUND
  The magnitude of intra- and inter-fractional variation in the set up of breast cancer patients treated with tangential megavoltage photon beams was investigated using an electronic portal imaging device (EPID).
  
  
  METHODS
  Daily cine-EPID images were captured during delivery of the tangential fields for ten breast cancer patients treated in the supine position. Measurements collected from each image included the central lung distance (CLD), central flash distance (CFD), superior axial measurement (SAM) and the inferior axial measurement (IAM). The variation of motion within a fraction (intra-fraction) and the variation between fractions (inter-fraction) was analysed to quantify set up variation and motion due to respiration.
  
  
  RESULTS
  Altogether 3775 EPID images were collected from 10 patients. The effect of respiratory motion during treatment was <0.1 cm standard deviation (SD) in the anterior-posterior (AP) direction. The inter-fraction movement caused by variations in daily set up was larger at 0.28 cm SD in the AP direction. Superior-inferior (SI) variation was more difficult to summarise and proved unreliable as the measurements were taken to an ambiguous point on the images. It was difficult to discern true SI movement from that implicated by AP movement.
  
  
  CONCLUSIONS
  There is minimal intra-fractional chest wall motion due to respiration during treatment. Inter-fractional variation was larger, however, on average it remained within departmental tolerance (0.5 cm) for set up variations. This review of our current breast technique provides confidence in the feasibility of utilising advanced treatment techniques (field-in-field, intensity modulated radiotherapy or volumetric modulated arc therapy) following a review of the current imaging protocol.
authors.affiliation: Division of Cancer Services, Radiation Oncology Mater Centre, Princess Alexandra Hospital Brisbane, Australia.
authors.forename: Scott
authors.initials: S
authors.lastname: Jones
authors.affiliation: Division of Cancer Services, Princess Alexandra Hospital Brisbane, Australia.
authors.forename: Rhys
authors.initials: R
authors.lastname: Fitzgerald
authors.affiliation: Division of Cancer Services, Radiation Oncology Mater Centre, Princess Alexandra Hospital Brisbane, Australia.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Owen
authors.affiliation: Division of Cancer Services, Radiation Oncology Mater Centre, Princess Alexandra Hospital Brisbane, Australia.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Ramsay
keywords: Breast cancer; motion; radiotherapy; radiotherapy set up errors