Skin markings methods and guidelines: A reality in image guidance radiotherapy era

Abstract

Preparation of site of radiation delivery is an important process in radiation treatment planning and plays a crucial role during a course of radiotherapy to achieve reproducibility of set-up and accuracy of treatment delivery. The preparation of treatment area is done by markings of field center, field edge or other reference point of planned field. Both non-invasive (marker pen, henna) and invasive methods (tattoo) are available for marking with limitations of each. Tattoo with a needle pricked at angle of 30° to 1-2 mm depth to create tattoo 2-3 mm diameter in size is an ideal procedure. Visibility, permanent nature, social-religious belief, and mobility of skin are one of the main concerns about tattoo. Tattoo removal can be done performed if desirable by patients by various modern ways, which will be esthetically available. Dermabrasion, cryotherapy, surgery, QSRL (Q-switched ruby laser) are common methods of tattoo removal. Esthetic dissatisfaction, allergy, dermatoses, keloids, infection, fanning/fading of tattoo are associated problems. In IMRT and IGRT treatment, delivery dependence on tattoo in reduced and use of surrogate markers including particularly for bony set-up and implanted markers (e.g. gold seeds) for tumor localization and treatment verification is increasing. However, these are complex procedures and require an expertise. Ease of set-up and less time required for tattooing are one of the main advantages of tattoo as compared to external or internal marker set-up. Tattoo still remains a crucial method of positioning, especially in developing countries and in palliative treatment settings.

Comparison of initial patient setup accuracy between surface imaging and three point localization: A retrospective analysis

“…These subcutaneous tattoos are traditionally placed medially and on both lateral sides using a permanent ink injected at a 30° angle perpendicular to the surface of the skin to a depth of 1–2 mm 1, 2. This configuration allows for a three point localization of the initial isocenter.…”

Skin fiducial markers enable accurate computerized navigation resection of simulated soft tissue tumors: A static cadaveric model pilot study

“…In the clinical setting, skin fiducial markers could be placed on the skin, and a standard surgical marking pen could be used to place an indelible “dot” in the center of each marker. Use of a permanent India ink tattoo represents another cost effective and widely used option for radiotherapy skin marking . On the day of surgery, the previously applied marks could then be used as reference points for computerized navigation system registration.…”

“…Use of a permanent India ink tattoo represents another cost effective and widely used option for radiotherapy skin marking. 30 On the day of surgery, the previously applied marks could then be used as reference points for computerized navigation system registration.…”

Quality improvement process to assess tattoo alignment, set‐up accuracy and isocentre reproducibility in pelvic radiotherapy patients

“…Treatment units with six degrees of freedom are commercially available but access to all patients in still limited. Furthermore, tattoo alignment continues to play an important role in identifying correct treatment sites, in patient groups without fiducial markers, in cases where daily IGRT is not appropriate or necessary, and where daily IGRT is not available such as radiotherapy centres in developing nations 11,12…”