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A Case Study of DIBH to Spare Abdominal Organs at Risk for Renal Cell Carcinoma MR-
Guided Radiotherapy

Steven Yorio RT(R)(VI)

Medical Dosimetry Program at the University of Wisconsin – La Crosse

I. Introduction
A. PI: Prevalence of renal cell carcinoma (RCC) as well as the statistics of it being
the most lethal of urologic malignancies and the populations affected by it
(Reference: Chin et al1, Ruhle et al2)
B. PII: Details RCC and the history of radioresitance for this type of tumor and the
need to use more aggressive and innovative treatments to spare organs at risk
(Reference: Chin et al1)
C. PIII: Discusses the effectiveness of deep inspiration breath holds (DIBH) to
control tumor motion during radiotherapy treatments, and the use of real-time
imaging radiation delivery using magnetic resonance linear accelerators
(MRLinac). (Reference: Chin et al, Naumann et al4)
D. PIV: Summarize introduction
1. Problem: Conventional methods for treating right renal cell
tumors can increase radiation toxicity to the colon and small bowel
without the use of motion management and real-time imaging.
2. Purpose: The purpose of this case study is to examine the
effectiveness of DIBH in sparing radiation dose to colon and small bowel
during MRLinac treatment of right sided RCC.
3. Goals: The case study goals when planning the treatment for MR-
Guided Radiotherapy (MRgRT) of RCC were to reduce dose to the colon
(G1) and the small bowel (G2).
II. Case Description
a. Patient Candidacy criteria for DIBH MRgRT
i. PI: Explanation of the inclusion criteria
1. Retrospective
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2. MRLinac treating renal tumor

3. Large amount of tumor motion with respiration
4. SBRT candidate
5. DIBH candidate
ii. PII: Highlight parameters for patient set up (figure 3)
1. Positioning devices
iii. PIII: Discuss patient simulation scans for treatment planning (figure 4)
1. 4D-CT, Nongated Mid Position scan
2. Breath Hold CT
a. Breath holds on deep expiration
b. Breath holds on deep inspiration
b. Clarify how the target is delineated before each fractional treatment
i. PI: Parallel contouring – Adapt to Shape (ATS)
1. Radiation Therapist
a. Non-deforming OAR
2. Physician
a. Targets: GTV, CTV, PTV
3. Physicist
a. Dose altering structures: air, bone, external
4. Motion monitoring contours
c. Highlight all treatment planning metrics and methods
i. PI: Treatment delivery details
1. Step and Shoot IMRT
a. Beams and segments
ii. PII: Explain the MRL Directives for each fractional treatment (Figure 7)
1. OAR constraints
iii. PIII: Motion Monitoring details
1. Single sagittal plane cine
2. Motion monitoring contour (Figure 6)
3. Breathing instruction process:
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a. RT(T) gave breath hold instructions to patient, turned beam

on when anatomy settled into position, and manually
paused beam after breath hold complete.
b. Total number of breath holds per fraction: 25-30
c. Total treatment time per fraction: 55-65 minutes
d. Plan Analysis and Evaluation
i. PI: Metrics for treatment analysis
1. Single patient study
2. Motion monitoring contour for dose accuracy (Figure 8)
3. Case study goals achieved
a. G1
i. Spare colon
b. G2
i. Spare small bowel
4. DVH statistics and dosimetric criteria (Figure 1)
ii. PII: Summary of treatment results and patient experience
1. Patient able to complete each fraction
2. No side effects observed during treatment
3. Accurate tumor placement with DIBH
iii. PIII: Discussion of patient follow-up and post treatment imaging.
1. Post-treatment PET/CT results
2. Adjuvant therapy complications and management
3. Metastasis
4. Subsequent diagnoses and treatments
III. Conclusion
a. PI: Summarize problem statement
b. PII: Summarize case study purpose
c. PII: Summarize results
d. PIII: Limitations/future treatments
i. Unique single patient involved in this study
ii. Reproducibility of treatment for other patients
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References

1. Chin A, Lam J, Figlin R, et al. Surveillance strategies for renal cell carcinoma patients
following nephrectomy. Rev Urol. December 2016.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1471767/. Accessed May 19, 2021.
2. Rühle A, Andratschke N, Siva S, et al. Is there a role for stereotactic radiotherapy in the
treatment of renal cell carcinoma? Radiother Oncol. 2019;18:104-112.
http://doi.org/10.1016/j.ctro.2019.04.012

3. Corradini S, Alongi F, Andratschke N, et al. MR-guidance in clinical reality: current

treatment challenges and future perspectives. Radiother Oncol. 2019;14(1).
http://doi.org/10.1186/s13014-019-1308-y
4. Naumann P, Batista V, Farnia B, et al. Feasibility of optical surface-guidance for position
verification and monitoring of stereotactic body radiotherapy in deep-inspiration breath-
hold. Front Oncol. 2020;10. http://doi.org/10.3389/fonc.2020.573279

5. Winkel D, Bol GH, Kroon PS, et al. Adaptive radiotherapy: The Elekta Unity MR-linac
concept. Clinic and Trans Radiat Oncol. 2019;18:54-59.
http://doi.org/10.1016/j.ctro.2019.04.001

6. Ding S, Li Y, Liu H, et al. Comparison of intensity modulated radiotherapy treatment

plans between 1.5T MR-Linac and conventional linac. Technol Cancer Res Treat.
2021;20:153303382098587. http://doi.org/10.1177/1533033820985871
7. Bergom C, Currey A, Desai N, et al. Deep inspiration breath hold: techniques and
advantages for cardiac sparing during breast cancer irradiation. Front Oncol. 2018.
http://doi.org/10.3389/fonc.2018.00087
8. Leyendecker JR, Brown JJ, Merkle EM, et al. Practical guide to abdominal and pelvic
MRI. LWW. (2010) ISBN:1605471445.
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Figures

Figure 1. DVH statistics and dosimetric criteria for targets and all OAR.
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Figure 2. IMRT constraints used for optimization of each fractional treatment.

Figure 3. Treatment table for Elekta Unity and patient set up with an adjustable arm board for
comfort.
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Mid Position

Deep
Expiration

Deep
Inspiration

Figure 4. Transverse, sagittal, and coronal images of CT scans using 4DCT, deep expiration
breath hold (DEBH), and deep inspiration breath hold (DIBH) for tumor location comparison.

Figure 5. Original scan MR scan (left)

compared to an optimized MR scan (right) to reduce parallel imaging reconstruction artifacts.
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Figure 6. Sagittal view of the motion monitoring structures, PTV (green) + Colon PRV (purple).
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Figure 7. Displayed is a list of step-by-step MRL Directives for the DIBH RCC treatment.

Figure 8. Motion monitored single frame of real time MR scan during treatment. Note placement
of tumor inside target contour during DIBH.