Int. J. Radiation Oncology Biol. Phys., Vol. 59, No. 3, pp.

861– 871, 2004

Copyright © 2004 Elsevier Inc.
Printed in the USA. All rights reserved
0360-3016/04/$–see front matter

doi:10.1016/j.ijrobp.2004.02.043

PHYSICS CONTRIBUTION

DOSIMETRIC EFFECTS WITHIN TARGET AND ORGANS AT RISK OF

INTERFRACTIONAL PATIENT MISPOSITIONING IN LEFT BREAST CANCER
RADIOTHERAPY

GUIDO BARONI, PH.D.,* CRISTINA GARIBALDI, M.S.,† MARCO SCABINI, B.S.,* MARCO RIBOLDI, M.S.,*
GIANPIERO CATALANO, M.D.,‡ GIANPIERO TOSI, M.S.,† ROBERTO ORECCHIA, M.D.,‡§ AND
ANTONIO PEDOTTI, M.S.*
*TBM Lab, Department of Bioengineering, Politecnico di Milano University, Milan, Italy; †Medical Physics Department and
‡
Radiotherapy Division, Istituto Europeo Oncologico-I.R.C.C.S., Milan, Italy; §Istituto di Scienze Radiologiche, Facoltà di
Medicina e Chirurgia, Università degli Studi di Milano, Milan, Italy

Purpose: To investigate the effects of interfraction setup uncertainties on the dose distribution within the clinical
target volume (CTV) and the organs at risk (OAR) of left-sided breast cancer patients undergoing external
radiotherapy.
Methods and Materials: Interfractional setup errors were assessed by measuring surface control points displace-
ments during 89 irradiation sessions in 4 patients, by means of opto-electronic localization. The measured
position deviations were fed back to the treatment planning system for the evaluation of the corresponding
dosimetric effects within CTV and OARs (lung, heart).
Results: Results revealed errors above 5 mm on some of the control points, but corresponding volumetric
variations were on average below 2% for both the CTV within the 95–105% dose range and the OARs receiving
more than 50% and 90% of the prescribed dose. A specific sensitivity to the setup errors was found as a function
of the treatment plan design, leading to isolated cases exhibiting volumetric variations of CTV and OARs
exceeding 2%.
Conclusions: This study confirms the potential increase of treatment quality provided by the systematic patient
position verification and highlights the role of opto-electronic position detection systems for the real-time check
of patient setup errors and the evaluation of the corresponding dosimetric consequences, as a way to achieve
consistent dose delivery. © 2004 Elsevier Inc.

Radiotherapy, Breast cancer, Treatment planning, Dosimetry, Quality assurance.

INTRODUCTION
Patient setup errors in the irradiation of breast cancer may
significantly affect the treatment quality. This applies par-
ticularly when tissue compensators are used or when inten-
sity-modulated beams are generated with the use of mul-
tileaf collimators, as a way to reduce dose inhomogeneities
within the target (1). In these cases, patient misalignments
and movements may alter the planned dose distribution and
potentially lead to complications or cause late radiation
effects. These include edema, skin fibrosis (1–3), pneumo-
nitis (4, 5), and heart diseases; the latter is associated with
left breast irradiation (6 – 8).
The frequency and magnitude of patient localization er-
rors and movements in breast cancer radiotherapy have been
investigated by means of portal imaging. As a whole, results
reveal that errors strongly depend on the specific protocol
for the irradiation geometrical setup and on the means used
for patient alignment (1, 9). In recent studies, the experi-
mental measurement of patient setup inaccuracies and organ
motion was used for the quantification of their effects on the
radiation dose distribution (1, 2, 10). Hector et al. (1–3)
used a method for the three-dimensional (3D) anatomic
structure reconstruction from portal images and quantified
the dosimetric consequences of interfractional patient
movements within the target volume, which they related to
different irradiation techniques.
An alternative approach to the quantitative assessment of
patient position repeatability is based on opto-electronic
localization. A basic feature of these systems is the real-time
3D localization of landmarks on the patient, identified by
infrared light-reflecting (passive) or light-emitting (active)
markers. The applicability and reliability of opto-electronic

Reprint requests to: Guido Baroni, Ph.D., Dipartimento di Bio- This work is partly supported by the Associazione Italiana per la
ingegneria, Politecnico di Milano, Piazza Leonardo da Vinci, 32, Ricerca sul Cancro (A.I.R.C.).
I-20133, Milan, Italy. Tel.: (⫹39) 02-2399-3346; Fax: (⫹39) Received Jul 28, 2003, and in revised form Feb 13, 2004.
02-2399-3360; E-mail: baroni@biomed.polimi.it Accepted for publication Feb 18, 2004.

861
862 I. J. Radiation Oncology ● Biology ● Physics
Fig. 1. (Left panel) Photograph of a breast cancer patient in treatment position with vacuum-formed cushion for
immobilization and supporting device. (Right panel) Three-dimensional graphic representation of the treatment
geometry; letters T, L, and H indicate target, lung, and heart, respectively.
localizers for the real-time detection of patient misalign-
ments in radiation therapy was experimentally investigated
(11, 12). Their clinical application in extracranial radiother-
apy as patient repositioning control devices was reported for
breast (13), prostate (14), and gynecologic cancer irradia-
tion (15).
In the present study, we report the results obtained by the
real-time monitoring of patient position during the treatment
of left-sided breast cancer by means of opto-electronic
position detection, including a respiratory gating protocol.
The detected misalignments were used to quantify the re-
lated dosimetric effects within the target volume and the
organs at risk (OAR) (lung, heart). This was obtained by
calculating a spatial transformation, describing the mea-
sured errors and feeding this information back to the treat-
ment planning system (TPS). The clinical aim of the study
was to check quantitatively whether the size and occurrence
of patient setup errors might alter significantly the planned
radiation dose distribution in patients undergoing radiother-
apy for breast cancer.
METHODS AND MATERIALS
The analysis was performed on a set of 89 acquisitions
from a group of 4 patients (age, 58.7 ⫾ 5.2 years), who gave
informed consent to be included in this study. Patient se-
lection criteria were mainly related to the specific clinical
approach (quadrantectomy followed by postoperative radio-
therapy) and to the side of the pathology (for the left breast,
heart is an OAR).
Irradiation technique
Treatment technique consisted of whole breast irradiation
with opposed tangential 6-MV photon beams and a pre-
Volume 59, Number 3, 2004
scription of 50 Gy at the isocenter delivered in 25 fractions,
followed by 10 Gy boost to the tumor bed. The patient was
lying in supine position on an inclined plane, immobilized
in a personalized, vacuum-formed cushion, with arms ele-
vated (Fig. 1). For each patient, a computed tomography
(CT)-based 3D treatment plan (Cadplan, Varian Medical
Systems, Palo Alto, CA) was performed, built on about 50
CT slices acquired contiguously with 0.5-cm spacing and
0.5-cm thickness.
The breast clinical target volume (CTV) was outlined on
each CT slice using the visible breast parenchyma; the
superficial CTV limit was defined to extend to 5 mm be-
neath the skin. In field definition, safety margins were added
in all directions to the CTV to take into account breathing
movements, setup errors, and beam penumbra. Particularly,
in cranial and caudal directions field edges extended 1.5 cm
from the CTV; superficially, the border of the field extended
in air with 1-cm margin. Adequate CTV coverage, central
lung distance not exceeding 2.5 cm, and avoidance of con-
tralateral breast irradiation were the criteria followed for the
deep field margin definition (Fig. 1).
The two considered OAR were heart and left lung. The
cranial limit of the heart included the infundibulum of the
right ventricle, the right atrium, and the right atrium auricle
and excluded the pulmonary trunk, the ascending aorta, and
the superior vena cava. The lowest external contour of the
heart was the caudal border of the myocardium. The peri-
cardium was not excluded from the heart volume. The
contour of the lung was automatically outlined.
Dose–volume histograms (DVHs) were computed for the
CTV and for the OARs and constituted the baseline data for
the quantification of the dosimetric deviations due to patient
localization errors detected at each daily fraction.
 Setup errors dosimetric effects in left breast irradiation ● G. BARONI et al. 863

Fig. 2. Control points selection procedure. Anatomic skin landmarks were highlighted by means of radiopaque markers
(upper left panel). The corresponding three-dimensional reference positions were manually extracted from the virtual
environment of the treatment planning software (upper right panel). For each patient, the resulting configuration
guaranteed the presence of: one control point in correspondence to the center of irradiation field (C); two control points
in correspondence to the tattoos on the mediosternal line (Tup, Tdown); two control points in correspondence to the upper
margin of the irradiation field (FupM, FupL); one control point in correspondence to the lower margin of the irradiation
field (Fdown). Two additional control points (R1, R2) placed on the transversal umbilical line were used for patient
breathing phase detection.

Acquisition of CT reference position Patient position detection system

The CT reference position was defined by identifying the
3D coordinates of a set of surface control points on the CT
slices used for treatment planning (Fig. 2). These were
selected in correspondence to the tattooed references on the
sternum used for manual patient alignment and to additional
natural skin marks identified on each patient. During CT
scan acquisition, the landmarks were highlighted by means
of radiopaque markers (3 mm in diameter). Their 3D posi-
tions were measured on the CT slice, which best displayed
the entire marker section. This procedure provided the CT-
based reference dataset. Interfractional patient setup errors,
measured at the therapy unit by means of the opto-electronic
patient position detection system (see “Acquisition of treat-
ment patient position”), were superimposed on the CT ref-
erence position to quantify the related dosimetric effects
(see “Quantification of the altered dosimetry”).
At each daily fraction, the patient was aligned at the
therapy unit by means of conventional manual alignment
techniques (laser centering), and the accuracy of patient
repositioning was monitored by means of an opto-electronic
position detection system (ELITE, B.T.S. Spa, Milan, Italy)
equipped with specific software for radiotherapy application
(Fig. 3) and breathing detection.
The system provided real-time detection and 3D recon-
struction of the position of reflective markers (radius, 5 mm;
fractions of gram in weight) included in the field of view of
a couple of infrared (750 – 820 nm) TV cameras (100 Hz
sample rate) installed in the therapy room. The calibration
procedure for the 3D marker localization was performed by
means of a 7 ⫻ 7 grid of markers, which was aligned to the
isocentric reference laser lines and acquired at five different
vertical positions of the treatment couch. The resulting
864 I. J. Radiation Oncology ● Biology ● Physics Volume 59, Number 3, 2004

Fig. 3. Schematic representation of hardware (left) and software (right) components of the opto-electronic localization
system. TVC1 and TVC 2 are the CCD infrared (IR)-light sensitive TV cameras equipped with IR LEDs (light emitting
diodes) for scene illumination. Markers on subjects appear as bright spots on the video images which are elaborated in
real time for marker 2D localization by means of shape cross-correlation. Markers are automatically labeled via software
exploiting the memorized 2D reference configuration of the control points. The application of stereophotogrammetric
techniques leads to the real-time three-dimensional reconstructions of markers position, the calculation of the control
points displacements, and the estimation of patient position correction parameters by means of a least-squares
minimization procedure.

reference system axes (x, y, z) of the opto-electronic local-
izer coincided with the latero-lateral, craniocaudal, and an-
teroposterior directions of the CT/linac units. In the frame of
this specific motion capture system setup (the calibrated
volume centered in correspondence to the linac isocenter
measured 480 ⫻ 480 ⫻ 160 mm3), errors in 3D marker
localization were assessed to be lower than 0.5 mm (stan-
dard deviation superimposed on the length of a marked stick
freely moved within the calibrated volume) (13).
Acquisition of treatment patient position
At each irradiation, the patient was positioned in the
vacuum cushion and arm-supporting device (Fig. 1) and
was manually centered at the therapy unit according to the
following procedure: the two sternal tattoos were aligned
along the sagittal laser reference line; the cranial tattoo was
positioned at the intersection between the sagittal and the
lateral laser lines at the prescribed source–skin distance; the
final patient setup was obtained by shifting laterally the
treatment couch according to the indication provided by the
treatment plan. Portal images of the two tangential fields
were acquired at the first irradiation session to check the
irradiation geometry. Patients were fitted with a set of
light-reflecting markers, applied in correspondence to the
skin landmarks selected during CT scanning. Markers’ 3D
positions were recorded for 15 s (1500 frames) immediately
before the irradiation (localization acquisition).
According to Baroni et al. (11, 13), the recorded markers’
coordinates underwent a specific data processing for breath-
ing movement compensation, consisting of:
 Setup errors dosimetric effects in left breast irradiation
1. Detection of patient breathing movements (opto-elec-
tronic respiratory gating). The 3D coordinates of two
additional markers placed on the transverse umbilical
line (R1 and R2 in Fig. 2) were used to reconstruct a
kinematic signal related to the thoracoabdominal move-
ments due to respiration.
2. The averaging of control points position only on the
frames corresponding to the minima of the obtained
breathing phase signal (EE, end of spontaneous
expiration).
This procedure was guaranteed to calculate the treatment
position with no influence of patient breathing or random
movements (within each acquisition, control points position
intrasession variability at the EE frames was checked to be
lower than 1.0 mm). To avoid biases in data comparability
between CT and the therapy unit and to valorize the mask-
ing of the influence of breathing on the measurement of
setup errors, the markers’ positions measured at the first
radiation session defined the treatment reference position.
Interfractional patient mispositioning was calculated by
comparing treatment reference and treatment current posi-
tions, which were obtained according to the above-de-
scribed data processing. This allowed us to quantify the pure
repositioning inaccuracies related to the intrinsic efficacy of
the conventional means of patient manual alignment.
Control points positions were again recorded during ir-
radiation (verification acquisition). In this case, data analy-
sis was finalized to quantify the peak position deviation,
which occurred during the irradiation. Among the set of
recorded frames, the one exhibiting the highest markers
displacement with respect to the reference position was
identified. This arose from a combination of setup inaccu-
racies, breathing, and random patient movements.
Quantification of the altered dosimetry
The difference between reference and current markers
coordinates was the first level of information related to the
accuracy of patient repositioning. These data were used to
evaluate the corresponding deviations in the absorbed dose
distribution, by means of the following procedure
1. Marker displacements measured at each irradiation were
superimposed on the corresponding CT reference data-
set, to define an irradiation-specific CT marker configu-
ration.
2. Specific software in MATLAB (The MathWorks Inc.,
Natick, MA) was developed to estimate the rigid spatial
transformation (roto-translation), which best interpreted
marker displacements between reference and current
configurations.
3. The irradiation geometry was altered in the treatment
plan system and a new dose distribution was calculated.
Marker redundancy (only three points are necessary to
describe a rigid spatial transformation) required the imple-
mentation of a least-squares algorithm, to estimate the best
transformation, which described the set of measured control
● G. BARONI et al. 865
points displacements. Among the six parameters (three ro-
tations and three translations) provided by the least-squares
algorithm, we were forced to discard the rotation around the
latero-lateral axis, due to an intrinsic limitation of TPS. The
least-square optimization procedure was therefore per-
formed on the remaining five parameters. Residual values of
the cost function (the squared sum of the marker displace-
ments) greater than zero were obtained in all cases. This
indicated, as expected, that the measured localization errors
could not be completely interpreted by a five-parameter
rigid roto-translation. The size of cost function residuals
was used to estimate the intrinsic accuracy of the proposed
rigid body approach. The five roto-translation parameters
were used for two purposes:
1. To simulate the improvement of patient position, as if the
radiographers would have acted on treatment couch and
gantry servo-controlled movements, according to the es-
timated roto-translation parameter
2. To alter the treatment geometry within the TPS accord-
ing to the following criteria:
—rotation around the craniocaudal axis was set by acting
on the gantry out-plane orientation;
—rotation around the anteroposterior direction was set
by acting on the table in-plane isocentric orientation;
—the three translations were set by acting on the 3D
position of the isocenter.
To ensure the dosimetric comparability with the original
plan, the new dose distribution was renormalized on the
original isocenter position and the field weights were even-
tually changed to preserve the monitor units delivered by
each field.
Dosimetric deviations with respect to the original treat-
ment plan were assessed on the differential DVHs for the
CTV and the OARs (lung and heart) in terms of percentage
variation of the volume included in predefined dose level
intervals. For the CTV, we computed the percentage varia-
tion of the volume receiving less than 95% (⌬V⬍95%) and
more than 105% (⌬V⬎105%) of the daily dose; for the
OARs, the percentage variations of the volume receiving
more than 50% (⌬V⬎50%) and 90% (⌬V⬎90%) of the daily
dose were calculated.
RESULTS
Setup errors
Figure 4 reports the linear displacements of the control
points with breathing compensation, with respect to the
reference configuration. Distribution fitting (Kolgomorov-
Smirnov statistical test) revealed that the displacements
were normally distributed around the mean values. The
analysis of variance (ANOVA) with displacement direction
as independent variable, followed by post hoc comparison
of means showed that the observed significant differences (p
⬍ 10⫺4) were imputable to dorsoventral repositioning er-
rors along the anteroposterior direction. ANOVA, applied
866 I. J. Radiation Oncology ● Biology ● Physics Volume 59, Number 3, 2004

Fig. 4. Linear marker displacements (mean ⫾ standard deviation, and highest-lowest values are reported as whisker
plots) along the three main anatomic directions. Data were averaged on a total of 89 irradiation sessions for the 4
patients. Marker positions are reported on the right figure panels.
 Setup errors dosimetric effects in left breast irradiation ● G. BARONI et al. 867

Fig. 5. Three-dimensional marker displacements (mean ⫾ quartile, and highest-lowest values are reported as whisker plots)
averaged on a total of 89 irradiation sessions for the 4 patients. Upper panel: 3D peak marker displacements identified on the
set of verification acquisitions. Middle panel: Marker displacements measured in correspondence to the end of spontaneous
expiration (EE) and used to evaluate the corresponding dosimetric deviations. Lower panel: 3D residual errors after the
hypothetical patient position correction by means of the least-squares estimated roto-translation parameters.
868 I. J. Radiation Oncology ● Biology ● Physics
Fig. 6. Frequency plot of volumetric variations of the clinical target volume (CTV) receiving less than 95% (⌬V⬍95%)
and more than 105% (⌬V⬎105%) of the prescribed dose (2 Gy) with respect to the original plan.
with the patient as an independent variable, did not show
significance differences.
Figure 5 depicts the corresponding 3D localization errors.
In the upper panel, the peak markers’ displacements de-
tected during the irradiation (verification acquisition) are
reported. According to the data analysis procedure, these
data represent the interfractional average of control points
displacements, measured in correspondence to the frame at
which the highest position deviation was detected.
When respiratory compensation was added in the data
analysis, the corresponding 3D patient misalignments (Fig.
5, middle panel) show that eliminating the influence of
breathing and random movements led only to a slight de-
crease of the median values and variability of setup errors.
Only the control points placed on the sternal tattoos (Tup,
Tdown in Fig. 2) were affected by 3D errors below 5 mm.
Noteworthy is the presence of control point displacements
up to 1.2 cm, which might represent the effects of isolated
macroscopic operator-dependent misalignments.
Figure 5 is completed by the residual 3D displacements
affecting the control points after the simulated application
of the position correction, described by the five-parameter
rigid transformation (lower panel). They represent the re-
sidual errors, if the patient position would have been cor-
rected by acting on the treatment couch and gantry.
CTV dosimetric variations
Figure 6 shows the dosimetric effects within the planned
target volume of the patients’ setup errors when breathing
movement effects were compensated. The results are re-
ported in terms of frequency distribution of the percentage
CTV volumetric variations outside the 95–105% dose range
with respect to the original treatment plan.
Outcomes revealed that mean values and data variability
(standard deviation, SD) were 1.0 ⫾ 2.1% and 0.4 ⫾ 0.7%
for ⌬V⬍95% and ⌬V⬎105%, respectively. The distribution of
Volume 59, Number 3, 2004
⌬V⬍95% shows the occurrence of nine isolated cases, ex-
hibiting volumetric variations of the CTV receiving less
than 95% of the prescribed dose greater than 2% and up to
12%. Statistical analysis (ANOVA, with patient as indepen-
dent variable, and post hoc contrast analysis Scheffé test)
revealed that the overall significant differences between the
examined patients (⌬V⬍95%: F (3, 85) ⫽ 4.91, p ⫽ 0.003)
were due to larger volumetric variations for one specific
patient (Patient 3) in comparison to the others (⌬V⬍95%:
lowest significance p ⫽ 0.025). Only four observations
exhibiting variations exceeding 2% in the ⌬V⬎105% distri-
bution were observed.
OAR dosimetric variations
Figures 7 and 8 report the frequency distribution of the
OARs (lung and heart) percentage volumetric variations
receiving more than 50% (⌬V⬎50%) and 90% (⌬V⬎90%) of
the daily dose. Lung volumetric variations (Fig. 7) exhibited
mean values and data variability of ⫺0.7 ⫾ 2.1% and ⫺0.4
⫾ 1.6%, respectively. ⌬V⬎50% and ⌬V⬎90% showed volu-
metric variations exceeding 2% in 11 and 7 cases, respec-
tively. Results account for a generalized decrease of
⌬V⬎50% and ⌬V⬎90% for 3 patients (mean ⫾ SD: ⌬V⬎50%
⫽ ⫺1.6 ⫾ 1.5%; ⌬V⬎90% ⫽ ⫺1.2 ⫾ 1.1%). The largest
positive variations were found for 1 patient (Patient 4), for
whom ⌬V⬎50% and ⌬V⬎90% were 1.5 ⫾ 1.6% and 1.3 ⫾
1.4%, respectively. Statistical analysis confirmed significant
differences for this patient in comparison to the others (p ⬍
10⫺6).
The percentage variations of the heart volume receiving
more than 50% and 90% of the daily dose (Fig. 8) were
found to vary between ⫺3.0 and ⫹ 3.0%, with notably low
average values and data variability (mean ⫾ SD: ⌬V⬎50% ⫽
⫺0.005 ⫾ 1.1%; ⌬V⬎90% ⫽ ⫺0.02 ⫾ 0.5%). Only three
cases with volumetric variations greater than 2% were ob-
served.
 Setup errors dosimetric effects in left breast irradiation ● G. BARONI et al. 869

Fig. 7. Frequency plot of volumetric variations of the left lung receiving more than 50% (⌬V⬎50%) and 90% (⌬V⬎90%)
of the prescribed dose (2 Gy) with respect to the original plan.

No variations with respect to the original plan were found
for 1 patient (Patient 2), and one isolated case (Patient 1)
showing noteworthy variations (⌬V⬎50% ⫽ 5.8%; ⌬V⬎90%
⫽ 3.2%) was observed. Statistical analysis revealed signif-
icant differences (⌬V⬎50%: p ⫽ 0.0005; ⌬V⬎90%: p ⫽ 0.03)
between data from Patient 1 and Patient 4.
DISCUSSION
In this work, the interfractional patient setup errors were
measured and their effects on the dose distribution were
quantified in patients undergoing external radiotherapy at
the left breast. With respect to previous studies relying on
portal imaging (1, 2, 10), the method was in this case based
on opto-electronic patient position verification, providing at
each irradiation session the displacements of a set of surface
control points with respect to a corresponding reference
configuration. The detected mispositioning was fed back
into the treatment planning system for the evaluation of the
resulting dosimetric alteration within the target and the
OARs (lung, heart).
With respect to the displacements of the external control
points, results agreed with a previous clinical study on 5
breast-cancer patients (13). When breathing movements
were compensated during data analysis (control points dis-
placements were measured at patients’ end of expiration),
only markers placed on the sternal tattoos used for patient
manual alignment exhibited on average an acceptable posi-
tion reproducibility (Figs. 4 and 5, middle panel). In partic-
ular, Tup turned out to be the best repositioned marker, as the
only reference that was directly checked by the radiogra-
phers to be at the point of intersection of the lateral and
sagittal reference laser lines and at the prescribed skin–
source distance. Considerably higher errors affected the
control points, which were relatively far from the directly
inspected skin landmarks, but still within or close to the
irradiation field. When the peak localization errors (includ-
ing the effects of breathing and random movements) were
measured, even higher median values and variability of the
displacements were found (Fig. 5, upper panel). The occur-
rence and size of the observed setup errors suggest that the
couple of skin tattoos (Tup, Tdown, see Fig. 2) used for

Fig. 8. Frequency plot of volumetric variations of the heart receiving more than 50% (⌬V⬎50%) and 90% (⌬V⬎90%) of
the prescribed dose (2 Gy) with respect to the original plan.
870 I. J. Radiation Oncology ● Biology ● Physics
manual patient alignment might not be enough to guarantee
an adequate patient repositioning, when patient position
verification methods (portal imaging or opto-electronic lo-
calization) are not applied systematically.
A least-square minimization procedure was applied to
condense the measured local displacements of the control
points into a five-parameter (two rotations and three
translations) spatial transformation. The simulation of the
corresponding patient position correction caused a dra-
matic reduction of the initial control points displacements
(Fig. 5, lower panel). Although recent studies have ques-
tioned the effective advantages of using opto-electronic
devices with respect to manual repositioning procedures
(15), this result agrees with previous clinical experience
(13, 14) and confirms that opto-electronic position detec-
tion systems might serve efficiently as patient reposition-
ing means, leading to a significant improvement of the
accuracy in patient setup.
The five-parameter spatial transformation was also esti-
mated from the CT-based dataset, and was used to alter the
treatment geometry within the plan, to quantify the corre-
sponding dosimetric alteration (see “Quantification of the
altered dosimetry”). From the methodological point of view,
the reliability of this approach is supported by the redundant
number of control points, by the application of a least-
squares procedure, and by the opto-electronic breathing
movement detection and compensation. This latter excluded
biases due to organ motion of CTV and OARs induced by
respiration. Furthermore, the least-squares estimation of the
roto-translation operator from multiple control points en-
sured that most of the interfractional soft tissue deforma-
tions and volumetric variations of the CTV were taken into
account. The intrinsic inaccuracies of the reported approach
are represented by the residual values of the cost function of
the least-squares minimization procedure. Actually, they
coincide with the residual errors reported in Fig. 5 (lower
panel). Their size is on average lower than the uncertainties
of the pseudo-CT set reconstruction from portal images (16)
and is put forward to represent an acceptable range of
confidence, within which the measured dosimetric devia-
tions were expressed.
The evaluation of the altered dose distribution within
CTV and OARs revealed that, although the observed patient
mispositionings were considerable, they did not generally
lead to critical underdosages or overdosages. This testifies
that the trade-off between the intrinsic efficacy of the con-
ventional methods of patient alignment and the criteria for
treatment plan design (beam’s eye view [BEV]) turned out
to guarantee sufficient dose homogeneity in the CTV and
OARs. Volumetric variations of the CTV outside the dose
range 95–105% were on average 0.7 ⫾ 1.6% (mean ⫾ SD).
However, among the 13 CTV volumetric variations outside
the 95–105% dose range, which overcame the action level
threshold (2%), 8 were observed in one single patient (Pa-
tient 3) in a total of 23 cases (35%). The same reasoning
applies to the OARs, which on average turned out to be
Volume 59, Number 3, 2004
affected by negligible variations of the volume receiving
more than 50% and 90% of the prescribed dose (see Fig. 7,
Fig. 8, and “Results” section). However, among the 11 cases
of lung ⌬V⬎50% higher than 2%, 9 were found for one
specific patient (Patient 4) on a total of 27 (33%). This same
patient was the one for whom the two cases of heart
⌬V⬎50% over 2% were observed.
Deterministic relationships between surface control
points displacements and dosimetric deviations could not
be established. Control points displacements turned out
to exhibit negligible differences between patients, thus
confirming that their size and occurrence are mainly
related to the specific means and procedures used for
manual patient alignment (9). On the contrary, a patient-
specific categorization of the corresponding dosimetric
effects was observed. This mainly depended upon the
modalities with which the CTV and the OARs were
drawn on the CT sets. As an example, it was clear that the
largest reduction of the CTV within the dose range 95–
105% for 1 patient was caused by the particular BEV
design, which was very close to the CTV internal tan-
gential border. In this case, even small patient misalign-
ments along specific directions could cause large percent-
age volume variations.
In conclusion, although it is difficult to give a clinical
interpretation of the described dosimetric deviations, the
reported results highlight the role of opto-electronic patient
localization systems for the quantification of size and oc-
currence of interfractional patient setup errors, as a function
of the efficacy of specific patient alignment and immobili-
zation devices. This information is considered essential for
the optimization of the CTV safety margins design, ac-
counting for patient-specific effects of mispositionings on
dose distribution (17). The availability of a quantitative
description in 3D of experimentally collected setup errors
can be used to assess a priori the sensitivity of the specific
PTV design to dosimetric deviations due to patients’ mis-
alignments (3). Conversely, the use of patient position ver-
ification methods during patient irradiation provides data for
the evaluation a posteriori of mispositioning dosimetric
effects, thus permitting one to undertake corrective proce-
dures for the remaining set of irradiations. In this frame, the
opto-electronic real-time detection of the 3D displacements
of surface control points emerges as an alternative, prom-
ising technique, alongside conventional portal imaging and
CT reconstruction methods, implying low time cost of op-
erator-dependent procedures for the verification of the do-
simetric effects of setup errors. The noteworthy advantages
are related to the real-time detection of localization errors,
to the possibility of differentiating the factors contributing
to the measured mispositioning (operator-dependant mis-
alignments, breathing movements), and to the potential ap-
plication of opto-electronic body surface detection and reg-
istration methods (18) for the measurement of changes in
breast morphology and volume over the course of treatment
(19).
 Setup errors dosimetric effects in left breast irradiation
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