Kylee McConnell

Breast Irradiation Using Deep-Inspiration Breath-Hold

RadSci 4389
Shannon Jordan
July 23, 2014

Introduction
For many years, patients have been receiving multiple types of breast radiation
treatments. Some treatments are more preferred by others. In previous years, the patients just
used the free-breathing (FB) technique, in which their respiration was not gated. This then lead
to the heart and lungs receiving a high amount of dose as well, which could cause radiation
pneumonitis, cardiac toxicity, or even secondary lung cancers. There have been many studies
conducted on the technique called deep-inspiration breath-hold (DIBH) that is used to reduce
the dose to the heart and lungs so it could lessen the probability that these problems occur. This
is important because this technique pushes the breast away from the heart, and it ensures
reproducibility since the breast cannot be treated unless the lung is in a certain threshold position.
The elements studied are the deep-inspiration breath-hold and free-breathing techniques
during breast tangential treatments. The dose volume histograms and plans are then compared to
see which technique will better the patients and keep the dose down to the heart and lungs.
Previous work has been done comparing women receiving breast radiation treatments using
either the DIBH or FB techniques. The research has shown that DIBH significantly reduces dose
to the lungs and heart, and it is more reproducible. This research has answered many questions
about the efficiency and reproducibility of these types of techniques. This has all lead me to
wonder if this DIBH technique really does work in reducing dose to the heart and lungs on a
larger population of women. It also makes me wonder if the late side effects will be as severe as
the FB side effects, or if there will be any effects in the lungs or heart at all.1
Hypothesis
I hypothesize that deep-inspiration breath-hold will be more effective in reducing dose to
the heart and lungs during left-sided breast irradiation. I believe that it will be reduced since the

lungs and heart will be out of the way during the treatments since the lungs have to be in a
certain threshold position before you can even turn the beam on. A critical prediction I have is I
also think that it will make the treatment accuracy more reproducible because of the threshold
respiratory position. Lastly, I believe that the long-term effects, such a radiation pneumonitis,
cardiac mortality, or secondary lung cancer, will be reduced since the heart and lungs will be
pushed out of the way of the beam.
Literature Review
Respiratory motion during breast irradiation is a major concern for patients for the risk of
cardiac toxicity or secondary lung cancers. The studies chosen focused on using deep-inspiration
breath hold to lessen the dose to the heart and lungs. Also, studies were done to measure how
much the heart and lungs move out of the way during treatment. These also stated the predicted
doses that these organs should get, which should be less than that of treatment without breathhold. The tolerance dose for the heart is 4000 cGy and the tolerance dose for the lungs is 1750
cGy. It is crucial that these organs do not receive more than that because of the late effects that
could appear.
This has all been an ongoing concern and study between many different physicians and
researchers in order to keep their patients from getting long-term side effects involving the heart
and lungs. Most of the studies done compare the results from deep-inspiration breath-hold with
the results of free-breathing treatment techniques. The deep-inspiration breath-hold technique
has a set threshold that the lungs must meet during breathing in order to even be able to beam on.
This clearly indicates that DIBH should be more effective to ensure consistency in the lung
position during the breast irradiation compared to free-breathing.

One drawback for these studies is the population chosen in the experiments. Most of the
studies only had between 8-25 women undergoing breast irradiation. Although this little amount
showed the effectiveness of breath-hold, more patients should have been studied to make sure
there truly was a difference and it was consistent. Also, deep-inspiration breath-hold and freebreathing are both very good techniques to compare, but in some studies, expiration breath-hold
was used. In order to find the truly best technique, all studies should have used all three
techniques to compare the results on. The DVHs were used in all of the studies to figure out and
examine the dose to the heart and lungs. This was definitely a great piece to look at, but these
studies did not necessarily talk about the long-term effects that could possibly arrive from the
treatments. The doses may look good on paper on the DVHs, but in the long run, what would be
better? Also, the mean ages studied were only mentioned in a few studies. Age truly makes a
difference when it comes to the outcomes and long-term effects. Younger patients might respond
differently to these treatments than older patients, and this needs to be compared in order to see
the true results.1,2,3,4,5,6
Methods
In a study done in the Department of Radiation of Oncology at The Ohio State
University, researchers created plans based on the CT simulator comparing the effects of deepinspiration breath-hold with free-breathing. DVHs were made to see the dosimetry involved in
these plans to the heart and lungs. Real-time Position Management (RPM) was used to track the
breathing process both in the CT simulator and treatment. Both the deep-inspiration and freebreathing scans were transferred to the AlignRT to confirm correct patient positioning and
respiration. MV images were taken in treatment to ensure the radiation beams were going exactly
where they were planned to go.1

In another experiment done by Bruzzaniti et al., eight patients were chosen and also
compared to using deep-inspiration and free-breathing. The patients were only receiving tangents
with either a 6 MV or 15 MV beam energy. DVHs were produced, highlighting the doses to the
heart and lungs. The tumor control probability (TCP) and normal tissue complication
probabilities (NTCP) were calculated to the heart and lungs, as well as the doses to the left
anterior descending coronary artery (LAD).2
Yonsei University College of Medicine also conducted a similar experiment using 25
patients who also used the deep-inspiration and free-breathing technique. The plans were
reconstructed reflecting exactly what the experiment was studying. Both the DIBH and FB plans
were compared according to their DVHs.3
In a study done at Hanseo University, 10 women were chosen to be compared against.
The mean age of these women was 44 years. This study not only used DIBH and FB, but it also
used expiration breath-hold (EBH) in the CT simulator. Plans were made and compared against
all of the 6 MV tangents fields of these patients who underwent breast-conserving surgery.4
Swanson et al., also conducted a similar study, but this one compared ninety-nine patients
who had Active Breathing Control (ABC), and eighty-seven of these patients used the DIBH
technique. Again in this study, the plans and DVHs for both DIBH and FB techniques were
compared.5
University of Michigans Department of Radiation Oncology also conducted a study like
the others named above. They used various breathing techniques either before or during the
patients treatment. They then looked at the placement of the beam compared to the LAD once
the patient was in full expiration. This also helped study how reproducible the position would be
during following treatments.6

In the experiment I would conduct, I would get around 100 patients who had already
undergone breast-conserving surgery. These patients would need to have a mean age around 50,
since that is about the average age the women will get breast cancer. I would take CT simulation
scans using DIBH, FB, and EBH and compare the DVHs of them. I would then chose patients
who have already had these types of treatments and look at their follow-ups in order to determine
the long-term effects of these types of breathing techniques. This is possibly a great way to
conduct this study because it considers each type of breathing technique, the patients are around
the same age, and late effects would be determined. Late effects are very critical to consider
when determining which treatment really does work best, considering these treatments are done
in order to reduce lung and heart problems.
Results
The results of the study done at The Ohio State University showed that there was a
reduction in heart dose using DIBH. Using RPM alone would not have much significance, but
AlignRT demonstrated to be very effective in gating using a threshold of 3-5 mm above and
below.1
The Bruzzaniti et al. experiment also showed the DIBH to be very effective. The mean
dose to the lungs was decreased by 16% or more. Pulmonary doses decreased by more than 20%.
LAD and heart doses were reduced by 78% when the DIBH technique was used. The NTCP for
mortality due to cardiac issues and pneumonitis decreased by 11%.2
The Yonsei University study proved DIBH to be very helpful, as well. The dose to the
heart using DIBH was around 2.52 Gy and FB was about 4.53 Gy. LAD dose using DIBH was
around 16.01 Gy, while the dose using FB was 26.26 Gy. The mean dose of the left lung using
DIBH was 7.53 Gy compared to the FB dose of about 8.03 Gy.3 The Hanseo University study

showed that the DIBH was much more effective in reducing dose to the heart compared to EBH
and FB.4
The Swanson et al. study also showed a large reduction in dose to the heart, by about
40%. The DIBH was 2.54 Gy compared to the FB dose of 4.32 Gy. There was also a 13%
reduction in dose to the lung. DIBH dose was 7. 86 Gy compared to the FB dose of 9.08 Gy.5
The University of Michigan study proved to have a 3 mm chance of reproducibility in the A-P
and L-R directions, and a 7 mm chance in the S-I direction.6
By all of the positive DIBH results reported from the studies above, I would assume that
my study would also prove that DIBH is very effective in reducing the dose to the heart and
lungs. I would also suggest that DIBH would be more reproducible and effective in reducing
long term side effects considering you are not irradiating as much of the heart and lungs as you
would be using the FB technique. This would be because you are expanding the lungs in your
deep-inspiration and moving you heart out of the way. Also, the positioning of your lungs would
be more reproducible since they would have to be in the threshold position to even turn the beam
on.
If my hypothesis was proven to be false, I would expect EBH to be effective in reducing
the dose to the heart and lungs. I suggest this just because it is also tracking your breathing and
making sure you can only beam on at a specific threshold instead of FB where your lungs and
heart could be in multiple different positions. The results of EBH are shown below where you
can see how EBH is second compared to DIBH. It is still reducing dose to the heart and lungs.
FB just shows to not be very effective at all when it comes to doses.4

References
1. Rong Y, Walston S, Welliver MX, et al. Improving Intra-Fractional Target Position Accuracy
Using a 3D Surface Surrogate for Left Breast Irradiation Using the Respiratory-Gated DeepInspiration Breath-Hold Technique. PLoS ONE. 2014; 9(5):97933.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3826503/pdf/1756-9966-32-88.pdf. Accessed
[June 30, 2014].
2. Bruzzaniti V, Abate A, Pinnaro P, et al. Dosimetric and clinical advantages of deep
inspiration breath-hold (DIBH) during radiotherapy of breast cancer. Journal of Experimental &
Clinical Cancer Research. 2013;32(88):1-7.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4031138/. Accessed [June 30, 2014].
3. Lee HY, Chang JS, Lee IJ, et al. The deep inspiration breath hold technique using Abches
reduces cardiac dose in patients undergoing left-sided breast irradiation. Radiat Oncol J. 2013;
31(4):239-246. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3912239/. Accessed [June 30,
2014].
4. Shim J, Kim J, Park W, et al. Dose-Volume Analysis of Lung and Heart according to Respiration

in Breast Cancer Patients Treated with Breast Conserving Surgery J Breast Cancer.
2012;15(1):105-110. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3318161/. Accessed [July 7,
2014].
5. Swanson T, Grills I, Ye H, et al. Six-Year Experience Routinely Utilizing Moderate Deep

Inspiration Breath-hold (mDIBH) for the Reduction of Cardiac Dose in Left-Sided Breast
Irradiation for Patients with Early Stage or Locally Advanced Breast Cancer. Am J Clin Oncol.
2013;36(1):24-30. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3375337/. Accessed [July 7,
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6. Jagsi R, Moran J, Kessler M, et al. Respiratory Motion of the Heart and Positional
Reproducibility Under Active Breathing Control. Int J Radiat Oncol Biol Phys. 2007;68(1):253258. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1865529/. Accessed [July 7, 2014].