# Breast radiotherapy positioning, immobilisation and daily set-up verification

Source: https://onco.cc/protocols/breast-radiotherapy-positioning-and-setup/  
OnCo record `breast-radiotherapy-positioning-and-setup` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

For breast or chest wall radiotherapy you usually lie on your back on a sloping board with both arms above your head, in the same position every day. Skin marks or a camera that maps your skin help line you up, and X-ray images, ideally daily, check your position before treatment. If lifting both arms is too hard, one arm up is an option; some departments treat larger breasts lying face down.

## Summary

The ESTRO-ACROP guideline (2023) is the only international guideline on breast set-up. Its recommendations: supine as the standard position for most treatments (it works with surface guidance); prone considered for larger breasts or more lung sparing where the equipment, expertise and patient tolerance allow; both arms up as more stable (one randomised study), one arm up for those who cannot tolerate it; flat or inclined boards both acceptable if collision risk is managed. There is insufficient evidence for any breast immobilisation device; bras or thermoplastic moulds may help selected patients with large or pendulous breasts, with skin dose evaluated locally.

Without surface-guided imaging, skin marks are required; the options (permanent tattoo, temporary marks) should be discussed with the patient, and the guideline notes that temporary marks may affect wellbeing less. For verification it recommends daily 2D-2D or 3D online imaging where available, matching on the bony anatomy under the treated volume and the breast tissue or contour, and warns against using surface guidance as the only verification without local validation, especially for partial-breast or boost treatment. Most of its statements rest on small studies; several are labelled considerations because the evidence could not support a recommendation. Breath-hold for left-sided treatment is a separate protocol.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: breast radiotherapy set-up; breast board; breast positioning for radiotherapy; radiotherapy skin marks; radiotherapy tattoos; breast IGRT; breast image guidance; prone breast radiotherapy; chest wall radiotherapy set-up

## Connected records

- protocols: [Deep inspiration breath-hold for left-sided breast radiotherapy](https://onco.cc/protocols/breath-hold-left-breast-radiotherapy/), [Radiotherapy dose and fractionation by cancer site: UK reference schedules](https://onco.cc/protocols/radiotherapy-dose-fractionation-reference/), [Radiotherapy planning scan (CT simulation): positioning, skin marks and what the patient does](https://onco.cc/protocols/radiotherapy-planning-ct-simulation/), [Skin care during radiotherapy and acute radiation dermatitis](https://onco.cc/protocols/radiation-dermatitis-skin-care/)
- cancers: [Breast cancer (all types)](https://onco.cc/cancers/breast-cancer/)
- technologies: [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [In-room imaging for radiotherapy (cone-beam CT, ExacTrac, CT-on-rails, HyperSight)](https://onco.cc/technologies/in-room-imaging-systems/), [Surface-guided radiotherapy (SGRT)](https://onco.cc/technologies/surface-guided-radiotherapy/)
- terms: [IMRT / IGRT / VMAT (modern external beam radiotherapy)](https://onco.cc/terms/imrt-term/), [Radiotherapy](https://onco.cc/terms/radiotherapy/), [Radiotherapy after mastectomy](https://onco.cc/terms/post-mastectomy-radiotherapy/)
- ideas: [Radiotherapy set-up without permanent ink tattoos, using surface guidance or invisible ink](https://onco.cc/ideas/idea-pu-tattoo-free-set-up/)

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