Radiotherapy and Oncology 90 (2009) 106–109

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Radiotherapy and Oncology

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Treatment verification

Use of skin markers and electronic portal imaging to improve verification

of tangential breast irradiation
Anke van der Salm a, Jennifer Strijbos a, Colette Dijcks a, Lars Murrer a,b,
Jacques Borger a,b, Liesbeth Boersma a,b,*
a
Maastro Clinic, Maastricht, The Netherlands
b
Department of Radiation Oncology (Maastro Clinic), GROW, University Hospital Maastricht, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: We investigated the added value of skin markers in 566 electronic portal images (EPIs) in 48 breast can-
Received 11 April 2008 cer patients treated with tangential fields. EPIs were matched to the corresponding DRRs using skin
Accepted 3 May 2008 markers, anatomy, or a combination of both. Skin markers improved determination of setup errors in cra-
Available online 12 June 2008
nio-caudal direction.
Ó 2008 Elsevier Ireland Ltd. All rights reserved. Radiotherapy and Oncology 90 (2009) 106–109
Keywords:
Portal imaging
Breast cancer
Skin markers
Treatment verification

Current methods for treatment setup verification of breast irra-
diation are usually based on matching bony anatomical landmarks,
as visible on the Electronic Portal Images (EPIs), to the same ana-
tomical landmarks visible in the digital reconstructed radiographs
(DRRs) [2–5,7–10]. Usually, portal images from the radiation fields
are taken [2–5,7–10], although sometimes separate orthogonal
additional beams are used, designed to check the isocenter [1].
However, verification of tangential breast irradiation using bony
anatomy may not be sufficiently adequate, since the target volume
(i.e. the breast) might move with respect to the bones. In addition
to this, some bony anatomy visible in the EPIs is located at some
distance of the target tissue (e.g. the spine). Recently, Bert et al.
[1] and Spadea et al. [6] both described a method that showed
the feasibility of the use of skin alignment instead of bony anat-
omy. They found a significant improvement in patient setup using
the skin alignment. Although the results of both studies were quite
good, these methods require installation of expensive new equip-
ment. Therefore, the aim of this study was to assess the feasibility
and additional value of a relatively simple and more generally
applicable method for portal imaging verification of patient setup
using skin markers, for patients treated with tangential fields.
We compared three methods of matching DRRs and EPIs: matching
based on anatomy only (lung and breast contour), skin markers
only, or a combination of anatomy and skin markers.
* Corresponding author. Maastro Clinic, Postbus 5800, 6202 AZ Maastricht, The
Netherlands.
E-mail address: liesbeth.boersma@maastro.nl (L. Boersma).
Patients and methods
Patients
Data were obtained in 48 breast cancer patients (Tis-4N0-2M0)
treated with post-operative radiotherapy. Thirty-seven patients
were treated with breast conserving therapy, and 11 patients were
referred for post-mastectomy radiotherapy. All patients were trea-
ted with tangential field irradiation.
CT-simulation and planning
CT-simulation was performed using a standard protocol. In
short, a planning CT was obtained with the patient in treatment
position. Three longitudinal laser lines and one transversal laser
line were positioned on the skin of the patient to ensure accurate
and reproducible positioning. The palpable breast tissue, or the re-
gion where palpable breast tissue was assumed to have been pres-
ent (after mastectomy) (i.e. the Clinical Target Volume – CTV) was
marked with a copper wire prior to the CT-scan. In addition, four
copper skin markers (Fig. 1A) were placed to mark the CTV at the
most cranial, caudal, medial, and lateral border of the palpable
breast tissue (CTV) (Fig. 1B). Each skin marker contains three
straight or round markers, enabling recognition of lateral (straight)
and medial (round) markers on the EPI in case of overprojection.
CT-images were obtained at 3-mm slice thickness from the level
of the mandible down to the diaphragm. The position of the skin
markers was indicated with ink to ensure reproducible placement

0167-8140/$34.00 Ó 2008 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.radonc.2008.05.014
 Anke van der Salm et al. / Radiotherapy and Oncology 90 (2009) 106–109 107

Fig. 1. Example of the skin markers (A), how they are placed onto the skin (B), and how they project in the DRR (C) and EPI (D). Each skin marker contains three straight or
round markers, spaced 1 cm apart. They are made of 1 mm copper (CT) or 1 mm gold (linear accelerator). The two shapes allow distinction of the lateral and medial markers.
The lateral and medial markers were shifted slightly in cranio-caudal direction to minimize overprojection. (C) The markers in the DRR, and (D) in the EPI. Clearly visible are
lung contour, breast contour, and four markers, denoted by Mcran, Mcaud, Mlat and Mmed for the cranial, caudal, lateral and medial markers, respectively. By manual
matching of the delineated structures with the EPI, values of the setup error are obtained in x- and y-direction of the beam’s eye view.

in treatment position. A small piece of TegadermTM was stuck over
these short lines, to prevent vanishing of the lines.
Standard tangential fields were designed using virtual simula-
tion. The copper markers at the CTV borders were delineated using
the treatment planning system (XiO, Computer Medical System,
Inc.) in order to be visualized on the digitally reconstructed radio-
graphs (Fig. 1C).
Radiation treatment and acquisition of EPIs
Patients were placed in correct position using the longitudinal
and transversal laser lines. The patient reference point was first
positioned to the machine isocenter and from there a table shift
was performed to move the patient to the correct position with
the isocenter in the breast. EPIs of the radiation fields were per-
formed weekly with the four skin markers in place. At the linear
accelerator gold markers were used with the same geometry as
the copper markers, for better visibility with megavolt imaging.
EPIs were made in both medio-lateral (ML) and latero-medial
(LM) directions using a Theraview-NT system (Cablon Medical)
[3] at a source detector distance of 150 cm. A total number of
566 EPIs was acquired, in a mean number of 5.9 fractions per pa-
tient (range 4–9 fractions).
Registration of the EPIs of the treatment fields with the DRRs
The displacement of the EPI with respect to the DRR was quan-
tified after manual registration with the corresponding DRR, using
Theraview-NT 2.4 (Cablon Medical) (Fig. 1D) [3]. The image regis-
tration was performed using three different methods:
(1) Anatomy match: Only using anatomical landmarks, i.e. the
lung and breast contour, thereby ignoring the skin markers
(these were not switched on in the reference contour set
during matching).
(2) Marker match: Only using the skin markers.
(3) Clinical match: Using the skin markers with additional help
of the anatomical landmarks. We assume that a pure marker
match will not be used in clinical practice, because using the
additional information of the visible anatomy is judged to be
superior to the use of markers only. Therefore, we added the
clinical match, which will be commonly used in clinical
practice.
Displacements were recorded in x- and y-direction in the
beam’s eye view of the separate fields. The y-direction represents
pure cranio-caudal direction, the x-direction represents a mixture
of left–right direction and table height, depending on the gantry
angle. Each type of match was performed by one of three observ-
ers. To estimate the interobserver variation, all matches were per-
formed by three observers, in a subset of ten patients with six
treatment fractions analyzed each. The interobserver variation for
one patient was calculated as the standard deviation of the three
match values per fraction, and was then averaged over all fractions
analyzed. The estimate of the interobserver variation for this sub-
population (and hence for the entire population) was determined
108 Skin markers for EPI in breast cancer
by averaging the mean standard deviation over these 10 patients.
The value of this mean standard deviation was small (1.1–
1.6 mm) for all directions.
Analysis of the match-data
First, the EPIs were analyzed qualitatively, to check whether the
skin markers (CTV) were located within the radiation portal. In pa-
tients where the position of the markers changed >3 mm with re-
spect to each other, only the cranial and medial markers were used,
since these were considered to be the most stable markers because
they are located at a relatively stable anatomy.
Next, the average setup error with standard deviation was cal-
culated for each patient in two directions, for both the ML and
the LM fields. Although we did not measure full 3D setup errors,
we analyzed our data in analogy to studies that applied 3D correc-
tions: (1) we calculated the systematic error (mean of means) for
each beam and each direction l0 , analogue to the l determined
in full 3D; (2) we calculated the SD of l0 (R0 ), analogue to the SD
of the systematic error R in full 3D and (3) we calculated the aver-
age of the SD per patient r0 , analogue to the SD of the random set-
up error r in full 3D [11]. These three parameters were calculated
for the three different matches. Finally, the difference between the
anatomy match, clinical match, and marker match was calculated
for each EPI in each direction. Differences between matches and
between the x- and y-direction were tested for significance using
the Students’ t-test. Assuming that a difference in match value
>5 mm is clinically relevant, we also evaluated the number of pa-
tients with an average difference >5 mm for the different matches.
Results and discussion
Overall setup accuracy
In all EPIs, the skin markers indicating the outline of the CTV on
the skin were located within the radiation field, indicating that at
least large setup errors did not occur. This was confirmed when
the match values were quantified. The mean of means l0 and R0
for all three types of matches were <1.8 mm and <3.6 mm, respec-
tively, in both the x- and y-direction, in both LM and ML fields.
The SD of the random error r0 was <3.6 mm in all beams and direc-
tions. The results of our ‘‘anatomy match” were comparable with
the results of other studies, using anatomical landmarks for match-
ing. In our study, R0 of the anatomy match varied from 2.1 to 3.3 mm
for the different beams and directions, whereas these figures varied
from 1.7 to 4.6 mm in other studies [2,4,5,7,9]. For r0 , these figures
were 2.3–3.1 mm in our study, vs. 1.7–3.4 mm in other studies [4,5].
An obvious limitation of this study is that we did not measure
setup errors in full 3D. We deliberately did not choose to use an
additional orthogonal EPI beam, to avoid additional radiation expo-
sure to the lungs, and to avoid increased workload at the linear
Table 1
Comparison of the different matches. Differences are given for the three different match procedures, for the ML beam and the LM beam, both in x- and y-direction of the beam’s
eye view
ML-x
(A) Average differences between each match ±SD (mm)
Anatomy – clinical match 0.1 ± 1.7
Clinical – marker match 0.1 ± 1.3
Anatomy – marker match 0 ± 2.1
(B) Number of patients (%) with an average difference over the entire treatment >5 mm
Anatomy – clinical match 0 (0%)
Clinical – marker match 0 (0%)
Anatomy – marker match 0 (0%)
The y-direction represents pure cranio-caudal direction, the x-direction represents a mixture of left–right direction and table height, depending on the gantry angle.
accelerator. By using only beam angles identical to the treatment
fields, we were unable to correct for setup errors in the direction
of the beam axis. However, since a setup error in that direction
only results in a different source skin distance, we considered the
effect of these setup errors on the dose-distribution to be of minor
importance. In patients in whom an additional boost to the tumor
bed is given using an additional orthogonal beam, this simple EPI
procedure obviously has to be extended with an additional orthog-
onal EPI-beam.
Comparison of the different matches
Comparison of the clinical, anatomy, and marker matches
showed no significant differences in average values of l0 , R0 , and
r0 . To analyze the data in more detail, we calculated the average
difference in match value between the methods per patient, and
subsequently averaged these values over all patients (Table 1A).
Although on average no significant differences were seen between
either of the matches (Table 1A), the SD of the average differences
between matches that both used skin markers (clinical and marker
matches) tended to be smaller (range 1.3–1.9 mm) than the SD of
the difference between matches that did use skin markers vs. with-
out skin markers (range 1.7–3.6 mm) (Table 1A). This suggests that
the clinical matched is dominated by the presence of skin markers
rather than by the anatomy.
Since we had the clinical impression that the markers were
especially helpful in cranio-caudal direction, we analyzed the var-
iation of the match-differences in more detail. We counted the
number of patients that would be matched differently by a clini-
cally relevant distance of >5 mm. We found that >5 mm differences
in the y-direction (on average over the entire treatment) were ob-
served in about 6% of the patients comparing the anatomy match
with the clinical match, whereas in x-direction all average differ-
ences were <5 mm (Table 1B). When comparing the anatomy
match with the marker match, this percentage was even higher
(10%) (Table 1B). Although these percentages obviously only repre-
sent a minority of patients, this observation stresses the impor-
tance of the use of the skin markers for detecting outliers in the
cranio-caudal direction. The additional value of the skin markers
in cranio-caudal direction is attributed to the lack of specificity
of the anatomical landmarks to correctly define the cranio-caudal
position as also pointed out by van Tienhoven et al. [7].
Feasibility of the use of skin markers
The position of the skin markers on the patient skin was marked
with ink as a short line. Tegaderm was used to cover the ink marks;
however, when the Tegaderm loosened from the skin, the ink line
could disappear completely. Therefore, we are currently using
Pointguards (www.beekley.com); this new material appears to
yield much less irritation of the skin, and stays longer securely in
ML-y LM-x LM-y
0.7 ± 2.8 0.1 ± 1.7 0.8 ± 3.0
0.2 ± 1.8 0 ± 1.6 0.3 ± 1.9
0.9 ± 3.2 0.1 ± 2.1 1.0 ± 3.6
3 (6%) 0 (0%) 3 (6%)
0 (0%) 0 (0%) 0 (0%)
5 (10%) 0 (0%) 5 (10%)
 Anke van der Salm et al. / Radiotherapy and Oncology 90 (2009) 106–109
place. The whole skin marker method appeared to be a very easy
and quick procedure, completely performed by the radiation tech-
nologists: 2 additional minutes at the CT simulator for placing the
skin markers into the skin, and for drawing the short inklines and
putting Tegaderm onto the skin, and 1 additional minute at the lin-
ear accelerator to place the skin markers when EPIs were made,
once a week.
A discrepancy >3 mm was observed in the configuration of the
four skin markers in about 30% of the measurements. In these
cases, only the medial and cranial markers were used for matching,
since the position of these markers was considered to be most sta-
ble. This may lead to the question whether all four markers are re-
quired for an adequate match. The reason for us to still stick to the
use of all four markers, is that in about 20% of the patients one of
the ink marks is lost. By using a redundancy of short lines (four) we
make sure that always at least two lines are preserved. In addition,
presence of the four markers also allows quick visual inspection, to
check whether all markers, which give a rough indication of the
CTV, fall within the radiation portal.
The discrepancy between the markers may be caused by either
a change in breast shape or an inaccurate placement of the skin
markers. A suspicion of persistent change in breast shape would
prompt a new CT-scan and treatment plan, especially of impor-
tance for the boost plan. However, in our patient group this was
necessary in only two cases.
Conclusions
We showed that skin markers in combination with bony ana-
tomical landmarks (‘clinical match’) facilitate and improve the
determination of setup errors in cranio-caudal direction. Although
a clinically relevant improvement was seen only in a minority of
patients (6%), skin markers are very easy to apply, and cause only
109
a minimal additional burden on the daily workload. The clinical
match is therefore now been employed routinely in our clinic.
The data concerning systematic and random errors will allow fu-
ture implementation of automated off-line setup verification and
correction protocols.
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