Journal of Radiotherapy in Practice

Original Article

The impact of inter-fraction set-up errors on the probability of pulmonary and cardiac complication in left-sided breast cancer patients

Crispen Chamunyonga 

The Cancer Centre, Nassau, Bahamas


Purpose This study evaluated the impact of patient set-up errors on the probability of pulmonary and cardiac complications in the irradiation of left-sided breast cancer.

Methods and materials Using the CMS XiO Version 4·6 radiotherapy planning system's normal tissue complication probability (NTCP) algorithm and the Lyman–Kutcher–Burman model, we calculated the dose–volume histograms (DVH) indices for the ipsilateral lung and heart and the resultant NTCP for radiation-induced pneumonitis and excess cardiac mortality in 12 left-sided breast cancer patients.

Results Isocentric shifts in the posterior direction had the greatest effect on the lung V 20, heart V 25, and mean and maximum doses to the lung and the heart. DVH results show that the ipsilateral lung V 20 tolerance was exceeded in 58% of the patients after 1 cm posterior shifts. Similarly, the heart V 25 tolerance was exceeded after 1 cm antero-posterior and left–right isocentric shifts in 70% of the patients. The baseline NTCPs for radiation-induced pneumonitis ranged from 0·73% to 3·4%, with a mean value of 1·7%. The maximum reported NTCP for radiation-induced pneumonitis was 5·8% (mean 2·6%) after 1 cm posterior isocentric shift. The NTCP for excess cardiac mortality were 0% in 100% of the patients (n = 12) before and after set-up error simulations.

Conclusions Set-up errors in left-sided breast cancer patients have a statistically significant impact on the Lung NTCPs and DVH indices. However, with a central lung distance of 3 cm or less (CLD < 3 cm), and a maximum heart distance of 1·5 cm or less (MHD < 1·5 cm), the treatment plans could tolerate set-up errors of up to 1 cm without any change in the NTCP to the heart.

(Received September 21 2013)

(Revised January 03 2014)

(Accepted January 13 2014)


  • breast cancer radiotherapy;
  • excess cardiac mortality;
  • NTCP;
  • radiation pneumonitis


Correspondence to: Crispen Chamunyonga, The Cancer Centre Bahamas, 72 Collins Avenue, Nassau, Bahamas. Tel: +1242 5029610. Fax: +1242 5029619. E-mail: