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This study systematically evaluates how focus region selection and registration direction affect DIR performance, providing evidence-based recommendations for clinical implementation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Materials and methods<\/jats:title>\n                    <jats:p>We analyzed 73 patients with left-sided breast cancer who underwent both free breathing (FB) and deep inspiration breath-hold (DIBH) planning CT scans. Clinical target volume (CTV), heart, left anterior descending artery, and both lungs were retrospectively contoured by one radiation oncologist on both datasets. Deformable Image Registration was performed bidirectionally (FB\u2194DIBH) using four different approaches: no focus region, CTV-focused, heart-focused, and surgical clip-focused registration. Volume differences and Dice Similarity Index (DSI) were calculated to assess registration accuracy. Generalized estimating equations analyzed possible correlations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Focus region selection critically impacted DIR accuracy. CTV-focused registration achieved highest CTV overlap (DSI: 0.96 vs. 0.91 without focus,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.005) but compromised other structures. Heart-focused registration optimized cardiac structure accuracy but reduced CTV precision. Registration direction showed minimal impact on volume differences but affected DSI values. Tidal volume significantly affected both CTV (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.005) and heart DSI (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.007), with opposite effects on each structure. Manual contour adjustment remained necessary in all cases regardless of parameter selection.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>DIR performance in breast radiotherapy is highly dependent on user-defined parameters, with no single configuration optimizing all structures simultaneously. Focus region selection creates a trade-off between local accuracy and global registration quality. Clinical implementation requires structure-specific parameter optimization and mandatory manual review. These findings establish practical limitations and benefits of hybrid DIR algorithms for breast radiotherapy workflows and highlight the continued necessity of expert oversight.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12880-026-02447-4","type":"journal-article","created":{"date-parts":[[2026,6,5]],"date-time":"2026-06-05T20:42:43Z","timestamp":1780692163000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Deformable image registration accuracy: impact of user-defined parameter selection on contour propagation for deep inspiration breath-hold and free breathing breast radiotherapy"],"prefix":"10.1186","volume":"26","author":[{"given":"Stefan","family":"Knippen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lea","family":"Pargmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steffen","family":"Weimann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guido","family":"Hildebrandt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kai Joachim","family":"Borm","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marciana Nona","family":"Duma","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,5]]},"reference":[{"issue":"9804","key":"2447_CR1","doi-asserted-by":"publisher","first-page":"1707","DOI":"10.1016\/S0140-6736(11)61629-2","volume":"378","author":"G Collaborative","year":"2011","unstructured":"Early Breast Cancer Trialists\u2019, Collaborative G, Darby S, McGale P, Correa C, Taylor C, Arriagada R, et al. 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IEEE Trans Med Imaging. 2010;29(1):196\u2013205.","journal-title":"IEEE Trans Med Imaging"}],"container-title":["BMC Medical Imaging"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12880-026-02447-4","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12880-026-02447-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12880-026-02447-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,25]],"date-time":"2026-06-25T12:04:11Z","timestamp":1782389051000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s12880-026-02447-4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,5]]},"references-count":44,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["2447"],"URL":"https:\/\/doi.org\/10.1186\/s12880-026-02447-4","relation":{},"ISSN":["1471-2342"],"issn-type":[{"value":"1471-2342","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,5]]},"assertion":[{"value":"19 January 2026","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"14 May 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"5 June 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This retrospective analysis was conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. The study involved only dosimetric evaluation of data acquired during routine clinical practice and did not include any additional interventions, imaging, or participation by human subjects. According to institutional and national regulations, retrospective dosimetric studies of this nature do not require individual informed consent. The requirement for ethics approval and informed consent was therefore waived by the Ethics Committee of the University Jena Medical School (Ethics Committee name: Ethikkommission der Friedrich-Schiller-Universit\u00e4t Jena, Reference number: 2021\u20132064).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"311"}}