A Prospective Study to Investigate the Placement of Setup Skin Markings for Larger Breasted Women Undergoing External Beam Radiotherapy (RT) for Breast Cancer
Authors: Doudoo Chris Osam , Roberts Neill , Amankwaa Frempong Emmanuel , Edusa Clement , Beecham Kwamena , Agyiri Kofi , Ahiagbenyo Promise , Acquah George Felix , Eric Abakuri Dominic Gadeka , Mordey Michael , Maria Anim Anna , Djan Bismark 
Published: March 2019

Background: The technique of placing all three skin marks (reference skin marks) on a single position during CT simulation for setup of patients undergoing conventional breast radiotherapy becomes a challenge when presented with larger breasted women (bra cup size ≥ D). A new way of using skin marks in setting these patients up has been developed where three skin marks are made on the patient (one on the sternum and two lateral skin marks more inferiorly beneath the breasts) for setup as against the departmental standard of using only a single skin mark on the sternum, and employing an SSD (Source to Skin Distance) technique.
This study therefore reviewed the placement of the skin markings for larger breasted women undergoing external beam radiotherapy for breast cancer by quantifying treatment field alignment errors and setup errors between the two different setup techniques.
Method: 36 patients were used in this study. Out of this number, 18 were setup using three reference skin marks and the remaining 18 were setup using one reference anterior skin mark. With an acceptable patient treatment field alignment error of 2 degrees, portal images (AP and lateral) of the different skin mark techniques were analysed for field alignment errors using an Iview GT system. More so, portal images (AP and lateral) of setup for both techniques were analysed for systematic (Σ) and random (σ) errors.
Results:The AP images of the single skin mark setup and the three skin mark setup yielded no significant difference as they recorded a p- value (p<0.05) of 0.089 and 0.110 respectively when compared to the treatment field alignment threshold error of 2 degrees. The lateral images of the three skin mark also yielded no significant difference as a p- value (p<0.05) of 0.091 was recorded. The lateral images of the single skin mark yielded a significant difference with a p- value (p<0.05) of 0.026.
Secondly, mean comparisons of the field alignment errors between the two setup techniques yielded no significant difference in the AP images as a p- value (p<0.05) of 0.089 was detected. On the contrary, a p- value (p<0.05) of 0.026 was recorded in the field alignment errors of the lateral images. This difference is significant.
Lastly, random errors were reduced in all directions (AP- anterior-posterior, SI- superior-inferior and LR- Left-right) in the three skin mark setup (4.5mm AP, 4.9mm SI and 2.4mm LR) as compared to the single skin mark setup (4.7mm AP, 5.2mm SI and 2.6mm LR). Systematic errors were also reduced in the three skin mark setup (1.7mm AP and 1.8mm SI) compared to the single skin mark setup (2.0mm AP, 2.1mm SI). Systematic errors in the LR direction on the other hand increased from 2.0mm in the single skin mark to 2.2mm in the three skin marks.
Conclusion
For setup of larger breasted women undergoing external beam radiotherapy for breast cancer, the three skin mark setup technique is superior to the single skin mark setup technique.