Setup uncertainties and the optimal imaging schedule in the prone position whole breast radiotherapy

Abstract

Background: To investigate the setup uncertainties and to establish an optimal imaging schedule for the prone-positioned whole breast radiotherapy.

Methods: Twenty prone-positioned breast patients treated with tangential fields from 2015 to 2017 were retrospectively enrolled in this study. The prescription dose for the whole breast treatment was 266 cGy × 16 for all of the patients and the treatments were delivered with the SSD setup technique. At every fraction of treatment, patient was firstly set up based on the body localization tattoos. MV portal imaging was then taken to confirm the setup; if discrepancy (> 3 mm) was found between the portal images and corresponding plan images, the patient positioning was adjusted accordingly with couch movement. Based on the information acquired from the daily tattoo and portal imaging setup, three sets of data, named as weekly imaging guidance (WIG), no daily imaging guidance (NIG), and initial 3 days then weekly imaging guidance (3 + WIG) were sampled, constructed, and analyzed in reference to the benchmark of the daily imaging guidance (DIG). We compared the setup uncertainties, target coverage (D₉₅, D_max), V₅ of the ipsilateral lung, the mean dose of heart, the mean and max dose of the left-anterior-descending coronary artery (LAD) among the 4 imaging guidance (IG) schedules.

Results: Relative to the daily imaging guidance (IG) benchmark, the NIG schedule led to the largest residual setup uncertainties; the uncertainties were similar for the WIG and 3 + WIG schedules. Little variations were observed for D₉₅ of the target among NIG, DIG and WIG. The target D_max also exhibited little changes among all the IG schedules. While V₅ of the ipsilateral lung changed very little among all 4 schedules, the percent change of the mean heart dose was more pronounced; but its absolute values were still within the tolerance. However, for the left-sided breast patients, the LAD dose could be significantly impacted by the imaging schedules and could potentially exceed its tolerance criteria in some patients if NIG, WIG and 3 + WIG schedules were used.

Conclusions: For left-side whole breast treatment in the prone position using the SSD treatment technique, the daily imaging guidance can ensure dosimetric coverage of the target as well as preventing critical organs, especially LAD, from receiving unacceptable levels of dose. For right-sided whole breast treatment in the prone position, the weekly imaging setup guidance appears to be the optimal choice.

Keywords: Image guidance frequency; LAD; Prone-positioned breast; Setup error.

Fig. 1

The prone position breast board (Lower Body Support, Wedge, Upper Body Support)

Fig. 2

A typical treatment plan of the prone position whole breast treatment. The yellow, cyan and pink line in breast is the dose line (100, 95, 70%); The straight yellow line is the beam line

Fig. 3

An example of the matched MV portal image with the corresponding DRR

Fig. 4

Residual setup errors in the vertical direction of the 4 IG schedules for one of the patients

Fig. 5

Doses of Organs at Risk for the 4 IG schedules. a V5 values of Ipsilateral Lung for all the 20 patients. b Heart mean doses. c LAD mean doses. d LAD maximum doses. b, (c) and (d) are for the 11 left-sided breast patients