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A comparison of free breathing (FB) and deep inspiration breath hold (DIBH) 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; Ashley Centar

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

I. Abstract
II. Introduction
A. PI: Breast irradiation OAR (Reference: Bergom,1 Kim et al,2 Reitz et al,3 Saini et al,4
Matsumoto et al5)
B. PII: Free breathing and deep inspiration breath hold (Reference: Bergom et al,1
Matsumoto et al,5 Gaal et al6)
C. PIII: Voluntary deep inspiration breath hold and moderate deep inspiration breath
hold (Reference: Bergom et al,1 Benkheld et al7)
D. PIV: Patient stressors and overexertion (Reference: Oonsiri et al,8 Kron et al,9 Nicolò
et al10)
E. PV: Summarize introduction points
1. Problem: The problem is that the OAR delineated on the FB simulation scans do
not align accurately to the cone beam CT (CBCT) scans on the first day of
treatment.
2. Purpose: The purpose of this retrospective study is to compare FB and DIBH CT
simulation scans and evaluate OAR shifts to determine if the potential cause of
the shifted CBCT OAR on first day treatment is due to the sequence of the scans.
3. Hypotheses: Researchers tested hypotheses that there will be a reduction of ≥10%
in shifts to the lungs (H1A) and heart (H2A) when changing the sequence of
simulation scans to FB followed by DIBH.
III. Materials and Methods
A. Patient selection and simulation set up
1. PI: Patient Population
a. 18 patients (9 DIBH CT first, 9 FB CT first)
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b. Inclusion Criteria (breast cancer, specific order of CT scans, CBCT

verification, FB scan used for treatment planning)
c. Exclusion Criteria (specific treatment technique: IMRT/VMAT vs 3D
conformal)
2. PII: Simulation Procedures
a. Alpha cradle
b. Elekta ABC set up (Figure 1)
B. Image Fusion
1. PI: Use of CBCT for fusion
a. Positioning Verification
2. PII: CBCT and CT fused based on chest wall
C. Contours
1. PI: OAR (Heart and Affected Side Lung) (Reference: Vicini et al11)
a. How the lungs were contoured
b. How the heart was contoured
D. Evaluation
1. PI: Point of shift measurements for each OAR
a. Coronal and transverse slices
2. PII: Shift calculation for each group
a. Mean shift for each group will be calculated
i. Group 1 lung and heart
ii. Group 2 lung and heart
E. PI: Statistical Analysis
1. Shapiro-Wilk test to determine the normality of the differences
2. t-test will be used for all metrics
3. P < 0.1 is considered statistically significant (one-tailed test)
IV. Results
A. PI: Lung Mean Shifts (Figure 3)
1. Mean lung shift Group 1 = 1.62 cm
2. Mean lung shift Group 2= 0.508 cm
3. Mean lung shift between the 2 groups P < 0.001 (statistically significant)
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4. Percent shift decrease 68.7% = Reject null hypothesis

B. PII: Heart Mean shifts (Figure 2)
1. Mean heart shift Group 1= 0.907 cm
2. Mean heart shift Group 2= 0.366 cm
3. Mean heart shift between the 2 groups P < 0.001 (statistically significant)
4. Percent shift decrease 64.7% = Reject null hypothesis
V. Discussion
A. PI: Summarize mean lung shifts in Group 1 and Group 2 in relation to CBCT and
Planning CT.
B. PII: Summarize mean heart shifts in Group 1 and Group 2 in relation to CBCT and
Planning CT.
VI. Conclusion
A. PI: Summarize the study
1. Problem: The OAR delineated on the FB simulation scans do not align accurately
to the cone beam CT (CBCT) scans on the first day of treatment.
2. Purpose: The purpose of this retrospective study is to compare FB and DIBH CT
simulation scans and evaluate OAR shifts to determine if the potential cause of
the shifted CBCT OAR on the first day of treatment is due to the sequence of the
scans.
B. PII: Limitations/future research
1. Limitations: all patients were collected from the same institution and the study
had a small sample size and CBCT scans were partial scans.
2. Future research: Increased sample size, include different institutions, and obtain
full CBCT scans to also include liver.
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References

1. Bergom C, Currey A, Desai N, Tai A, Strauss JB. Deep inspiration breath hold:
techniques and advantages for cardiac sparing during breast cancer irradiation. Front
Oncol. 2018;8(87). https://doi.org/10.3389/fonc.2018.00087.
2. Kim A, Kalet AM, Cao N, et al. Effects of preparatory coaching and home practice for
deep inspiration breath hold on cardiac dose for left breast radiation therapy. Clin Oncol.
2018;29(9):571-577. https://doi.org/10.1016/j.clon.2018.04.009.
3. Reitz D, Walter, F, Schönecker S, et al. Stability and reproducibility of 6013 deep
inspiration breath-holds in left-sided breast cancer. Radiat Oncol. 2020;15:121.
https://doi.org/10.1186/s13014-020-01572-w
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in left-breast irradiation in the supine and prone positions and with deep inspiration
breath-hold. J Appl Clin Med Phys. 2018;19(4):195-204.
https://doi.org/10.1002/acm2.12382.
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with breast conservative radiotherapy using abdominal and thoracic deep-inspiration
breath-holds: a comparative dosimetric study. J Appl Clin Med Phys. 2023;24(4):e13888.
https://doi.org/10.1002/acm2.13888
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patient training for deep inspiration breath hold technique of left-sided breast on
computed tomography simulation procedure at King Chulalong Memorial Hospital.
Radiat Oncol J. 2019;37(3):201-206. https://doi.org/10.3857/roj.2019.00290.
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9. Kron T, Bressel M, Lonski P, et al. TROG 14.04: multicentre study of feasibility and
impact on anxiety of DIBH in breast cancer patients. Clin Oncol. 2022;34(9):e410-e419.
https://doi.org/10.1016/j.clon.2022.05.020.
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monitoring: from healthcare to sport and exercise. Sensors. 2020;20(21):6396.
https://doi.org/10.3390/s20216396.
11. Vicini FA, Winter K, Freedman GM, et al. NRG RTOG 1005: a phase III trial of hypo
fractionated whole breasts irradiation with concurrent boost vs. conventional whole
breast irradiation plus sequential boost following lumpectomy for high risk early-stage
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12. Elekta. Active Breathing Coordinator. Elekta.com.
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July 13, 2023.
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Figures

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.