1

A comparison of free breathing and deep inspiration breath hold simulation scan sequence
due to CBCT OAR shifts for breast radiotherapy

Ryann Edwards, BS; Milica Ilic, BS, RT(R); Nishele Lenards, PhD, CMD, RT(R)(T), FAAMD;
Ashley Hunzeker, MS, CMD

Medical Dosimetry Program at the University of Wisconsin - La Crosse, WI

Introduction
Breast radiotherapy aids in the local control and survival rate for breast cancer patients,
but there is concern over cardiac toxicity relating to radiation therapy. The heart is one of the
major organs at risk (OAR) for breast radiotherapy, especially in the case of left side-breast
radiotherapy. Radiation exposure to the heart is the most well-known risk factors for developing
coronary artery disease and cardiac mortality.1,2 The risk of heart disease and coronary events is
estimated to increase 4-7% for every 1 Gy in mean heart dose.1,3 Saini et al4 showed that there
was a 50% relative reduction in the mean heart left anterior descending artery dose between free
breathing (FB) and breath hold (BH) plans. Along with the heart, the lungs are also one of the
other primary OAR to evaluate in breast radiotherapy. Heart and lung mean doses drastically
decrease using abdominal and thoracic breath hold methods.5
Limiting patient movement has been a consistent priority to ensure patients are not
shifting and are receiving the correct prescribed dose to the corresponding area of the body
during the treatment process.5 Respiration should be closely monitored and evaluated closely in
all imaging specialties. Medical advancements have included the use of deep inspiration breath
hold (DIBH) techniques as an aid in regulating patient breathing and as a tool to improve OAR
sparing during treatment planning.1 During a CT simulation scan for breast radiotherapy, there
are several techniques to manage motion, DIBH being one of them.1 Deep inspiration breath hold
is a technique in which the patient takes a deep breath and then holds it for a period during the
CT simulation. This technique is based on the observation that during inspiration, the diaphragm
flattens, the lungs expand, and the heart is pulled away from the chest wall.1,6 The DIBH
technique has been beneficial for many patients who receive breast radiotherapy. Utilizing the
DIBH technique increases distance from the chest wall and provides a more optimal physical
location for treating the affected breast tissue while limiting dose to OAR.

Deep inspiration breath hold techniques include 2 different commonly used methods
which are voluntary DIBH (vDIBH) and moderate DIBH.1 Patients that undergo vDIBH are
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instructed to hold their breath at certain points in the breathing cycle. Depending on the type of
equipment available, this often includes gating patient respirations by placing a device on the
patient’s chest or abdomen to measure vertical displacement. Treatment is withheld when the
patient is not at a desirable volume threshold.1 Moderate DIBH includes connecting patients to
Active Breathing Coordinator (ABC) devices to allow for monitoring of airflow and ensure that
patients remain at a desired breath hold volume.1 An ABC device utilizing the moderate DIBH
method encompasses a spirometer-based valve system to monitor airflow and lung volume of the
patient on a screen provided both in the room for the patient and for therapists outside of the
treatment room.7 Physicians will often order both an FB and BH CT simulation to be completed
for evaluation prior to beginning the treatment planning process due to the possible benefits
patients may receive by using a DIBH method.
While deep inspiration breath hold techniques provide benefits to patient treatment, not
all patients can undergo the process of DIBH without complications or overexertion. Due to
these possibilities, physicians elect to have both simulation scans completed. If the physician
finds there to be no considerable reduction in dose to OAR using the DIBH scan, the FB scan
will be used. Additionally, if the patient faced difficulties and overexertion with the ABC
devices, the FB simulation scan will be used. Oonsori et al8 suggested that the patient is likely to
feel an immense amount of pressure during the BH simulation scan, which deteriorates the
success of the DIBH technique. The session can take around 20-30 minutes, which can make the
patients uncomfortable and increase their stress and anxiety as a result.8 Kron and Bressel et al9
found that the mean anxiety score for 30 breast cancer patients performing a DIBH for CT
simulation was 4.3 out of 10, with 13% of them feeling ‘quite a bit’ or ‘very much’ worried they
would not hold their breath correctly. The sensitivity to an individual’s respiratory rate can be
directly affected by various factors and stressors, especially emotional stressors. 10 Thus, patients
need to be properly coached in the process of the DIBH CT scan and allowed time to adapt to the
clinical setting. Without the proper preparation and exposure prior to obtaining simulation scans,
the patient will not be in the same physical and emotional state they will be on the first day of
treatment. Radiation therapists and physicians can review patient anatomy by evaluating a cone
beam CT (CBCT) scan on the first day of treatment. These CBCT scans are used to track patient
anatomy and positioning to ensure little to no variation is present. However, proper coaching and
preparation are crucial for DIBH scans due to potential patient anxiety and stress.
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Protocols for the sequence of FB and DIBH simulation scans may vary among clinical
sites and are often based on physician preference. One concern is that the FB scan may not
accurately represent the patient's true condition, as it may show residual anxiety impacts from
emotional stressors and overexertion caused by the prior DIBH scan. This can become
problematic when the physician elects to use the FB scan over the BH scan for treatment
planning. To address this issue and ensure proper patient positioning and OAR alignment, OAR
are delineated on the FB simulation scan used for planning. However, challenges arise when
comparing the delineated OAR with the OAR on CBCT scans taken on the first day of treatment.
The misalignment between the FB simulation and CBCT scans can affect the accuracy of patient
positioning and tracking patient progression, potentially leading to treatment discrepancies.
Therefore, establishing consistent protocols for the sequence of simulation scans and refining the
alignment process between FB and CBCT scans is crucial for enhancing the precision and
effectiveness of radiation therapy treatments. The problem is that the delineated OAR from the
FB simulation scans do not line up accurately to the CBCT scans on the first day of treatment.
Therefore, the purpose of this retrospective study is to compare FB and DIBH CT
simulation scans and evaluate OAR shifts to determine if the cause of the shifted CBCT
OAR on first day of treatment is due to the sequence of the scans. Researchers tested
hypotheses that there will be a reduction of ≥10% in shifts to the lungs (H1A) and heart
(H2A) when the sequence of simulation scans was altered to FB followed by DIBH.

Methods and Materials

Patient Selection and Simulation Setup
A total of 18 patients who received breast radiotherapy from a single institution were
selected for this retrospective study. The inclusion criteria were patients treated for breast cancer
with a specific order of CT simulation scans. Patients included were those who had a CBCT
verification on the first day of treatment and treatments whose were planned on the FB
simulation scan. Group 1 consisted of patients who were simulated DIBH first, followed by a FB
scan. Group 2 consisted of patients who were simulated for a FB simulation scan first, followed
by a DIBH scan second. Of the 18 patients, 9 had FB scan prior to DIBH scan and the 9 had
DIBH scan prior to FB scan. Treatment techniques used for planning were not considered.
Affected breast side with disease was not considered as the study encompassed both left and
right sided patients.
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Each patient underwent a DIBH CT simulation and a FB CT simulation. For positioning

reproducibility, patients were simulated supine with their arms raised and immobilized in an
Alpha Cradle for both the DIBH CT and FB. For the DIBH CT each of the patients were
simulated with the Elekta ABC device to monitor their breathing patterns and ensure patients
withheld a constant air volume threshold (Figure 1). A Phillips Big Bore CT scanner was used to
acquire the planning CTs with 3 mm slice thickness. The anatomy included on the simulation
scans began superiorly at the level of the mandible and extended inferiorly through the
diaphragm.

Image Fusion
Prior to treatment delivery, radiation therapists performed a CBCT scan for patient
alignment of the treatment area to the planning FB CT. The CBCT scans from day 1 of treatment
were fused to the treatment planning FB scan to evaluate the location of the heart and the
affected ipsilateral lung utilizing Medical Imaging Management (MIM). A rigid based fusion
was completed for every patient with the CBCT from day 1 of treatment and FB treatment
planning scan. The MIM software application was utilized for the alignment of the CW for all
patient fusions. The chest wall was referenced during fusing due to limited changes in anatomy.
Contours
Following fusions of the scans, the heart and the lungs were contoured on all CBCT
scans. The heart and lungs were contoured following the guidelines suggested by the Radiation
Therapy Oncology Group (RTOG) 1005 and RTOG 1106 protocols for breast and thoracic
irradiation.11 The heart contour begins inferior to the bifurcation of the pulmonary artery. The
mediastinal heart tissue following this bifurcation was included on every slice inferiorly leading
to the diaphragm and along the pericardium. The affected ipsilateral lung was contoured using an
auto segmentation feature with manual verification using lung window levels. This included the
apex of the lung superiorly and to the base of the lung inferiorly.
Evaluation
Evaluation of anatomy shifts utilized both the coronal plane and the transverse plane. The
coronal plane was referenced to obtain shift measurements for the lungs. Measurements for the
lung were taken at a point midplane and at mid-depth of the lung for all patient scans. Shifts for
the lung were measured at the most inferior aspect near the bases as this is where lung motion
and movement are most affected due to the diaphragm and liver employing the measuring tool
available in MIM. For right-side affected patients, the liver dome was used as a reference and for
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left-sided patients the diaphragm was used as point reference. The transverse plane was used to
obtain measurements for the heart. The points of measurement for the heart were recorded at a
point midplane and mid-depth for all patients. The shift measurement was taken from the edge of
the delineated OAR on the planning CT to the corresponding edge of the delineated OAR on the
CBCT. The mean shift in centimeters (cm) for each group for the heart and lungs was calculated
and used for statistical analyses.
Statistical Analysis
The OAR shift measurements were reviewed to determine the appropriate method for
statistical analysis. Shapiro-Wilk tests were used to determine the normality of the differences in
each group. Both data sets for the heart and lungs in each group were analyzed. The Shapiro-
Wilk test deemed the data sets to be normally distributed. A two-sample t-test was performed for
all metrics to determine if the difference in means between both groups was statistically
significant. Following the recorded data sets' evaluation, a one-tailed test was used because of
the decrease in shifts presented between groups. Due to a small sample size, a significant p value
of P < 0.1 was utilized to find a significance more adequately in the data set.

Results
Lung Mean Shifts
The mean lung shift for Group 1 was 1.62 cm and the mean lung shift for Group 2 was
0.508 cm (Figure 2). The amount of shift present in the lungs for Group 1 ranged from 0.61 cm
to 2.68 cm. In comparison, the amount of shift present in Group 2 ranged from 0.22 cm to 1.05
cm. Upon evaluation of the t-test, a clinically significant difference between the 2 groups was
observed (P= 0.001). Upon evaluating the mean lung shifts of both groups, there is a 68.7%
reduction of shifts seen between Group 1 and Group 2. Therefore, researchers rejected the null
hypothesis (H10) and witnessed a decrease in lung shifts > 10%.
Heart Mean Shifts
The mean heart shift for Group 1 was 0.907 cm and the mean heart shift for Group 2 was
0.366 cm (Figure 3). The amount of shift present in the heart for Group 1 ranged from 0.38 cm to
1.73 cm. In comparison, the amount of shift present in Group 2 ranged from 0.22 cm to 0.67 cm.
Upon evaluation of the t-test, a clinically significant difference between the 2 groups was
observed (P= 0.001). Upon evaluating the mean heart shifts of both groups, there is a 64.7%
reduction of shifts seen between Group 1 and Group 2. Therefore, researchers rejected the null
hypothesis (H20) and witnessed a decrease in heart shifts > 10%.
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Discussion

Conclusion

Acknowledgements
The authors would like to thank Dr. Douglas Baumann of the Statistical Consulting
Center at the University of Wisconsin - La Crosse for assistance with analysis and interpretation
of statistical data; however, any errors of fact or interpretation remain the sole responsibility of
the authors.
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Figures
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Figure 1. Elekta ABC device (courtesy of and with permission from Elekta).

Figure 2. Box-whisker plot of measured lung shifts (cm) for Group 1 and Group 2.
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Figure 3. Box-whisker plot of measured heart shifts (cm) for Group 1 and Group 2.