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To compare the differences in setup errors measured with electronic portal image ( EPI ) and cone‐beam computed tomography ( CBCT ) in patients undergoing tangential breast radiotherapy (RT). Relationship between setup errors, body mass index ( BMI ) and breast size was assessed.    Methods  Twenty‐five patients undergoing postoperative RT to the breast were consented for this study. Weekly  CBCT  scans were acquired and retrospectively registered to the planning  CT  in three dimensions, first using bony anatomy for bony registration ( CBCT ‐B) and again using breast tissue outline for soft tissue registration ( CBCT ‐S). Digitally reconstructed radiographs ( DRR ) generated from  CBCT  to simulate  EPI  were compared to the planning  DRR  using bony anatomy in the V (parallel to the cranio‐caudal axis) and U (perpendicular to V) planes. The systematic ( Σ ) and random ( σ ) errors were calculated and correlated with  BMI  and breast size.    Results  The systematic and random errors for  EPI  ( Σ  V  = 3.7 mm,  Σ  U  = 2.8 mm and  σ  V  = 2.9 mm,  σ  U  = 2.5) and  CBCT ‐B ( Σ  V  = 3.5 mm,  Σ  U  = 3.4 mm and  σ  V  = 2.8 mm,  σ  U  = 2.8) were of similar magnitude in the V and U planes. Similarly, the differences in setup errors for  CBCT ‐B and  CBCT ‐S in three dimensions were less than 1 mm. Only  CBCT ‐S setup error correlated with  BMI  and breast size.    Conclusions   CBCT  and  EPI  show insignificant variation in their ability to detect setup error. These findings suggest no significant differences that would make one modality considered superior over the other and  EPI  should remain the standard of care for most patients. However, there is a correlation with breast size,  BMI  and setup error as detected by  CBCT ‐S, justifying the use of  CBCT ‐S for larger patients.

Comparison of setup accuracy of three different image assessment methods for tangential breast radiotherapy