Patient setup accuracy in DIBH radiotherapy of breast cancer with lymph node inclusion using surface tracking and image guidance

Studying setup accuracy in breast cancer patients with axillary lymph node inclusion in deep inspiration breath-hold (DIBH) after patient setup with surface-guided radiotherapy (SGRT) and image-guided radiotherapy (IGRT). Breast cancer patients (N = 51) were treated (50 Gy in 25 fractions) with axillary lymph nodes within the planning target volume (PTV). Patient setup was initiated with tattoos and lasers, and further adjusted with SGRT. The DIBH guidance was based on SGRT. Orthogonal and/or tangential imaging was analyzed for residual position errors of bony landmarks, the breath-hold level (BHL), the skin outline, and the heart; and setup margins were calculated for the PTV. The calculated PTV margins were 4.3 to 6.3 and 2.8 to 4.6 mm before and after orthogonal imaging, respectively. The residual errors of the heart were 3.6 ± 2.2 mm and 2.5 ± 2.4 mm before and 3.0 ± 2.5 and 2.9 ± 2.3 mm after orthogonal imaging in the combined anterior-posterior/lateral and the cranio-caudal directions, respectively, in tangential images. The humeral head did not benefit from daily IGRT, but SGRT guided it to the correct location. We presented a slightly complicated but highly accurate workflow for DIBH treatments. The residual position errors after both SGRT and IGRT were excellent compared to previous literature. With well-planned SGRT, IGRT brings only slight improvements to systematic accuracy. However, with the calculated PTV margins and the number of outliers, imaging cannot be omitted despite SGRT, unless the PTV margins are re-evaluated.