1

A comparison of respiratory motion scan sequences to improve cone beam computed

tomography 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 Cetnar, PhD, DABR

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

ABSTRACT
Establishing standardized protocols for simulation scan sequencing plays a pivotal role in
ensuring consistent patient positioning for treatment delivery. Protocols for the sequence of free
breathing (FB) and deep inspiration breath hold (DIBH) simulation scans may vary among
clinical sites and could be due to physician-based preference or lack of standardization within
clinical practice. Challenges specifically emerge when comparing the delineated organs at risk
(OAR) on the FB simulation scan with those on cone beam CT (CBCT) for patients who were
simulated using DIBH technique prior to the FB technique. The problem is that the delineated
OAR from the FB simulation scans may not align accurately to the CBCT images on the first day
of treatment. Therefore, the purpose of this retrospective study was 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 in shifts ≥10% to the lungs (H1A) and heart (H2A) when the sequence of
simulation scans was altered to FB followed by DIBH. Researchers found that altering the
sequence of FB and DIBH simulation scans yields a significant decrease in OAR shifts. When
the FB scan preceded the DIBH scan, there was a 68.5% reduction in lung shifts and a 59.3%
reduction in heart shifts from the contours used for treatment planning. These results suggest that
initiating with FB scans prior to DIBH during CT simulation can contribute to improved lung
and heart positioning and setup accuracy.
KEYWORDS: Breast Radiotherapy, Deep Inspiration Breath Hold, Free Breathing, Simulation
Protocols
Introduction
Breast irradiation aids in the local control and survival rate for breast cancer patients. 1
However, there is concern over cardiac toxicity relating to radiation therapy and other organs at
risk (OAR) toxicities such as the ipsilateral lung. The heart is one of the major OAR for breast
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radiotherapy, especially in the case of left side-breast radiotherapy due to the location of the
heart positioned slightly to the left of midline within the chest cavity. The risk of heart disease
and coronary events are estimated to increase 4-7% for every 1 Gy in mean heart dose.1,2 Saini et
al 3 showed a 50% relative reduction in the mean heart left anterior descending artery dose
between free breathing (FB) and breath hold (BH) plans. In addition to the heart, it is essential to
assess the lungs as additional critical OAR during breast radiation therapy. Close monitoring of
lung doses is crucial to mitigate potential pulmonary complications and secondary cancers. 3
Effective motion management strategies, along with personalized planning, are crucial to
minimize the radiation dose to surrounding tissues.
Sustaining a persistent approach to restrict patient motion ensures that patients remain
fixed, receiving the correct prescribed dose in the intended area of their body during treatment.4
Minimizing the impact of respiratory motion on target accuracy reduces the risk of collateral
damage to healthy tissues, thus enhancing treatment effectiveness and patient safety. Motion
management techniques include innovative methods like deep inspiration breath hold (DIBH),
serving as a vital tool in optimizing radiation therapy treatment outcomes. Deep inspiration
breath hold is a technique in which the patient takes a deep breath and then holds the inspiration
position for a period during the CT simulation which is reproduced during treatment. This
technique is based on the anatomical observation that during inspiration, the diaphragm flattens,
the lungs expand, and the heart is retracted from the chest wall.1,5 Utilizing the DIBH technique
increases the distance of the heart from the chest wall and provides a more optimal physical
location for treating the affected breast tissue while limiting the dose to OAR. A DIBH technique
such as an Active Breathing Coordinator (ABC) can be used to monitor the patient’s airflow and
ensure the desired breath hold volume is constant. An ABC device incorporates a spirometer-
based valve system to monitor the airflow and lung volume of the patient on a screen provided
both in the room for the patient and for radiation therapists outside of the treatment room. 6
Treatment beam delivery is withheld when the patient is not at a desirable lung capacity. 1
Physicians will often order both an FB and DIBH CT simulation for evaluation prior to
the treatment planning process to assess the possible benefits left sided breast patients may
receive by using a DIBH method. While employing DIBH techniques often yield OAR sparing,
not all patients can tolerate DIBH without encountering complications related to patient setup or
overexertion. Due to these possibilities, it is standard at most clinics to complete both scans for
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treatment planning evaluation. If the physician found there was no considerable reduction in dose
to OAR using the DIBH scan or there were concerns of patient overexertion, the FB scan was
used for treatment planning.
Oonsori et al7 suggested the patient is likely to feel an immense amount of physical and
emotional pressure during the DIBH simulation scan, which can decrease the technical
advantages of the DIBH technique. The session can take around 20-30 minutes, which could
increase patient’s stress and anxiety.7 Kron et al8 found, of 30 breast patients 13% worried ‘quite
a bit’ or ‘very much’ that they would not be able to hold their breath correctly. The sensitivity to
an individual’s respiratory rate can be directly affected by various factors and stressors,
especially emotional stressors.9 Acknowledging a patient's emotional state is imperative as the
emotional state may impact simulation scan quality. This impact could be potentially significant
for patients simulated in the sequence of DIBH prior to FB.
Establishing standardized protocols for simulation scan sequencing plays a pivotal role in
ensuring consistent patient positioning for treatment delivery. Protocols for the sequence of FB
and DIBH simulation scans may vary among clinical sites and could be due to physician-based
preference or lack of standardization within clinical practice. If the DIBH scan is acquired first in
the sequence, the FB scan may not accurately represent the patient's normal free breathing
conditions, 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 DIBH scan for treatment. To provide a reference for accurate patient
positioning during treatment and structures for optimization during treatment planning, OAR are
delineated on the FB simulation scan. Challenges specifically emerge, however, when comparing
the delineated OAR on the FB simulation scan with those on cone beam CT (CBCT) for patients
who were simulated using DIBH technique prior to the FB technique. The problem is that the
delineated OAR from the FB simulation scans may not align accurately to the CBCT images on
the first day of treatment. Therefore, the purpose of this retrospective study was to compare the
order of the 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 correlated to the sequence of the
scans. Researchers tested hypotheses that there will be a reduction in shifts ≥10% to the lungs
(H1A) and heart (H2A) when the sequence of simulation scans was altered to FB followed by
DIBH.
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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 sequence of CT simulation scans and a CBCT scan for positioning verification on
the first day of treatment. Included in the study were patients whose treatments were planned
based 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 an FB simulation
scan first, followed by a DIBH scan second. The techniques used in treatment planning and the
distinction between left and right-sided patients were not considered, as the study encompassed
individuals with diseases on both breast sides. However, most patients included in the study were
left sided cases (n=13). For positioning reproducibility, patients were simulated supine with their
arms raised and immobilized in an Alpha Cradle for both the DIBH CT and FB CT. 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 3.0 mm slice thickness.
The anatomy included on the simulation scans began superiorly at the level of the mandible and
extended inferiorly through the diaphragm.
Treatment Image Registration
Patients in this study cohort underwent treatment planning utilizing tangent breast
techniques or volumetric modulated arc therapy (VMAT). For this study, day 1 FB CBCT scans
were registered retrospectively to the treatment planning FB scans using Medical Imaging
Management (MIM) software. The registration process employed a rigid-based approach and
alignment was centered on the ipsilateral chest wall for all patients due to minimal anatomical
changes in this region. This registration technique ensured precise evaluation of heart and
ipsilateral lung positions, laying the foundation for accurate analysis of organ shifts.
Contours
Following registration of the planning and treatment images, the heart and the lungs were
contoured on the CBCT scans following treatment delivery. The heart and lungs were contoured
following the guidelines recommended by the Radiation Therapy Oncology Group (RTOG) 1005
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and RTOG 1106 protocols for breast and thoracic irradiation.10 For consistency, one individual
completed all contours for this study.
Shift Evaluation
Anatomical shifts were assessed using both the coronal and transverse planes of the
images. The sagittal plane was not referenced for measurements due to the coronal and
transverse planes most accurately representing the anatomy of interest. The coronal plane was
referenced to obtain shift measurements for the lungs (Figure 2). Lung measurements were taken
at the mid-plane and mid-depth of the lung in all patient scans, focusing on the inferior aspect
near the bases, where lung motion is most affected. The measurements were made using the
available measurement tool in MIM. For right-side affected patients, the liver dome was used as
a reference and for left-sided patients the diaphragm was used as point reference. The transverse
plane was used to obtain measurements for the heart (Figure 3). Heart measurements were taken
at the mid-plane and mid-depth for all patients, and shift measurements were calculated from the
delineated OAR edge on the planning CT to the corresponding edge of the heart on the CBCT.
The absolute value 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. The Shapiro-Wilk test was used to determine the normality of the differences
in data sets for the heart and lungs and deemed the data sets to be normally distributed. Using a
calculating resource provided by Social Science Statistics, a two-sample t-test was performed for
both metrics to determine if the difference in means between both groups was statistically
significant. 11 A one-tailed test was used based on the hypothesized results that Group 2 will
exhibit less shifts in OAR with P-value < 0.05 to evaluate statistical significance.
Results
Lung Mean Shifts
The mean lung shift for Group 1 was 1.62 cm with a standard deviation of 0.86 cm and
the mean lung shift for Group 2 was 0.51 cm with a standard deviation of 0.27 cm (Figure 4).
Outliers were defined as data points displaying > 3 standard deviations from the central tendency
of the dataset. 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.
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Upon evaluating the mean lung shifts of both groups, there was a 68.5% reduction of shifts
observed between Group 1 and Group 2. Upon calculation of the t-test, a statistically significant
difference between the 2 groups was observed (P= 0.001); therefore, researchers rejected the
null hypothesis (H10).
Heart Mean Shifts
The mean heart shift for Group 1 was 0.91 cm with a standard deviation of 0.43 cm. The
mean heart shift for Group 2 was 0.37 cm with a standard deviation of 0.14 cm (Figure 5).
Outliers were defined as data points displaying > 3 standard deviations from the central tendency
of the dataset. 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 for Group 2 ranged from 0.22 cm to 0.67 cm. In assessing the
mean heart shifts of both groups, there was a 59.3% reduction of shifts observed between Group
1 and Group 2. Upon evaluation of the t-test, a clinically significant difference between the 2
groups was observed (P= 0.001); therefore, researchers rejected the null hypothesis (H20).
Discussion
In this retrospective study comparing the impact of the sequence of FB and DIBH CT
simulation scans on OAR shifts, significant reductions in both lung and heart shifts were
observed when the FB scan was completed before the DIBH scan. The results demonstrated a
substantial 68.5% reduction in lung shifts and a 59.3% reduction in heart shifts between Group 1
and Group 2. These results suggest that initiating with FB scans prior to DIBH during CT
simulation can contribute to improved lung positioning and setup accuracy.
Oechsner et al12 explored the effects of DIBH on lung expansion in patients treated for
left-sided breast cancer. The study revealed an average lung expansion of 1.22 ± 0.46 cm
inferiorly between the FB scan and the DIBH scan in that sequence. In Group 1 of this study,
there was an average shift of 1.62 cm superior of the lung bases when the DIBH scan was
performed prior to the FB scan, demonstrating a similar shift difference when the simulation
scan order is reversed. Thus, the lung shifts in Group 1 could be attributed to residual effects
from the preceding DIBH scan before FB. This can further be evaluated in CBCT scans of Group
2 patients with an average shift of 0.51 cm at the bases of the lungs.
The evaluation of heart mean shifts similarly revealed a statistically significant difference
between Group 1 and Group 2. Reproducing the position of the heart is of paramount importance
in breast radiotherapy as excess radiation exposure to the heart is a well-known risk factor for
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coronary artery disease and cardiac mortality.3 These results suggest that initiating the simulation
process with FB scans may contribute to more favorable heart positioning, which can potentially
minimize the risk of cardiac toxicity. These results emphasize that initiating with FB scans could
contribute to improved OAR positioning stability, enhanced radiation therapy setup accuracy,
and reduced radiation exposure to healthy tissue.
Although not directly investigated in this retrospective study, a possible cause in the
increase of shifts in Group 1 OAR could be associated with patient preparation and anxiety
during the simulation process. Deng et al13 found that 50% of patients were ineligible to
participate in DIBH treatments due to the inability to complete coaching evaluation successfully.
The inability to participate in DIBH treatments were due to multiple reasons including physical
capabilities and emotional state when performing the DIBH scans. Completing the FB scan prior
to the DIBH would keep the patient in their typical resting state for respiration during the FB
scan. Introducing the DIBH technique following this scan would potentially minimize patient
anxiety and overexertion resulting from the DIBH would not affect the FB scan.
Conclusion
Establishing standardized protocols for simulation scan sequencing plays a pivotal role in
ensuring consistent patient positioning for treatment delivery. Protocols for the sequence of FB
and DIBH simulation scans may vary among clinical sites and could be due to physician-based
preference or lack of standardization within clinical practice. Challenges specifically emerge
when comparing the delineated OAR on the FB simulation scan with those on CBCT for patients
who were simulated using the DIBH technique prior to the FB technique. The problem is that the
delineated OAR from the FB simulation scans may not align accurately to the CBCT images on
the first day of treatment. Therefore, the purpose of this retrospective study was to compare FB
and DIBH CT simulation scans and evaluate OAR shifts to determine if the cause of the shifted
CBCT OAR on the 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. Altering the
sequence of FB and DIBH simulation scans yielded a significant influence on OAR shifts. When
the FB scan preceded the DIBH scan, there was a 68.5% reduction in lung shifts and a 59.3%
reduction in heart shifts from the contours used for treatment planning with no outliers presented
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in the data sets. The findings indicate that a standard protocol should be implemented in which
FB scans should be performed prior to DIBH scans.
A limitation of this study included a limited population size (n=18) at a single institution.
Including a larger number of patients from multiple institutions could enhance the reliability of
the study findings. Another limitation was that the CBCT images were obtained from partial
scans due to machine filter limitations only scanning 20.0 cm around the isocenter and inability
to complete a full scan without colliding with the patient. Therefore, future research should
include utilizing a larger field of view to incorporate more of the patient tissue. Incorporating full
CBCT scans also allows for the opportunity to accurately determine trace lung volumes between
the FB treatment simulation scan and the CBCT scan completed on the first day of treatment. A
further limitation of the study was the number of respiratory cycles included on each image set,
which could potentially be a cause for differences observed. Future research should also
incorporate volumetric analysis of the OAR center of mass compared with the linear measured
shift values.
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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10. Vicini FA, Winter K, Freedman GM, et al. NRG RTOG 1005: a phase III trial of hypo
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Figures

Figure 1. Elekta Active Breathing Coordinator (ABC) device (courtesy of and with permission
from Elekta) correctly demonstrated for proper utilization and patient set up.
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Figure 2. Coronal image of Group 1 patient visualizing lung displacement in FB condition

(orange) and CBCT condition (yellow).
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Figure 3. Axial image of Group 1 patient visualizing heart displacement in FB condition (red)
and CBCT condition (blue).
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Figure 4. Box and whisker plot of measured lung shifts (cm) for Group 1 and Group 2.

Figure 5. Box and whisker plot of measured heart shifts (cm) for Group 1 and Group 2.