Journal of Radiation Oncology

, Volume 8, Issue 1, pp 89–96 | Cite as

Comparison of deep inspiration breath hold and free breathing technique in left breast cancer irradiation: a dosimetric evaluation in 40 patients

  • Dario AielloEmail author
  • Giuseppina Rita Borzì
  • Lorenza Marino
  • Vincenza Umina
  • Alfio Michelangelo Di Grazia
Original Research



To analyze the reduction of dose to organs at risk between deep inspiration breath hold (DIBH) and free breathing (FB) techniques in left breast irradiation.


Forty left-sided breast cancer patients received adjuvant radiotherapy and were retrospectively analyzed. Treatment plans were generated on both DIBH and FB computed tomography (CT) scans. The patients were monitored by the Varian RPM™ respiratory gating system. The treatment planning was performed with conformal tangential fields by means of 6 and 10 MV photon fields. Treatment schedule were 50 Gy in 25 fractions (conventional schedule) or 40.05 Gy in 15 fractions (hypofractionated schedule), with or without sequential boost to tumor bed. Dose-volume histograms were compared for all plans. For the comparison, we considered cardiac and ipsilateral lung doses and volumes. Quantitative statistical analyses of plans dose differences were generated. In order to correlate the mean cardiac dose difference between the FB and DIBH techniques with maximum heart distance (MHD), a linear regression model was used.


A statistically significant reduction of cardiac and pulmonary doses using the DIBH technique was achieved compared with FB plans, maintaining an equal coverage of planning target volume (PTV). A positive correlation was found between MHD and mean heart dose difference.


Our study confirms the DIBH technique advantage in reducing cardiac and pulmonary doses for tangentially treated left-sided breast cancer patients. Further research is warranted to evaluate potential long-term clinical implications of these relevant dosimetry results.


Breast cancer Radiation therapy Gating Deep inspiration breath hold Cardiac dose Left anterior descending coronary artery 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of ethical standards

This article does not contain any studies with human or animal subjects performed by any of the authors.


  1. 1.
    American Cancer Society, (2007) Statistics for 2007: Cancer Facts & Figures. 0.asp
  2. 2.
    National Institute for Health and Care Excellence. Breast Cancer (early and locally advanced) diagnosis and treatment guidelines. National Institute for Health and Care Excellence. Online available from:
  3. 3.
    Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), Darby S, Mc Gale P, Correa C, Taylor C, Arriagada R et al (2011) Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 378:1707–1716CrossRefGoogle Scholar
  4. 4.
    EBCTCG (Early Breast Cancer Trialists’ Collaborative Group), McGale P, Taylor C, Correa C, Cutter D, Duane F et al (2014) Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet 383:2127–2135CrossRefGoogle Scholar
  5. 5.
    Taylor CW, Nisbet A, McGale P, Darby SC (2007) Cardiac exposures in breast cancer radiotherapy: 1950s-1990s. Int J Radiat Oncol Biol Phys 69(5):1484–1495CrossRefGoogle Scholar
  6. 6.
    Henson KE, McGale P, Taylor C, Darby SC (2013) Radiation-related mortality from heart disease and lung cancer more than 20 years after radiotherapy for breast cancer. Br J Cancer 108(1):179–182CrossRefGoogle Scholar
  7. 7.
    McGale P, Darby SC, Hall P, Adolfsson J, Bengtsson NO, Bennet AM, Fornander T, Gigante B, Jensen MB, Peto R, Rahimi K, Taylor CW, Ewertz M (2011) Incidence of heart disease in 35,000 women treated with radiotherapy for breast cancer in Denmark and Sweden. Radiother Oncol 100(2):167–175CrossRefGoogle Scholar
  8. 8.
    Darby SC, Ewertz M, McGale P, Bennet AM, Blom-Goldman U, Brønnum D, Correa C, Cutter D, Gagliardi G, Gigante B, Jensen MB, Nisbet A, Peto R, Rahimi K, Taylor C, Hall P (2013) Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med 368:987–998CrossRefGoogle Scholar
  9. 9.
    van den Bogaard VA, Ta BD, van der Schaaf A, Bouma AB, Middag AM, Bantema-Joppe EJ, van Dijk L, van Dijk-Peters F, Marteijn LA, de Bock GH, Burgerhof JG, Gietema JA, Langendijk JA, Maduro JH, Crijns AP (2017) Validation and modification of a prediction model for acute cardiac events in patients with breast cancer treated with radiotherapy based on three-dimensional dose distributions to cardiac substructures. J Clin Oncol 35(11):1171–1178CrossRefGoogle Scholar
  10. 10.
    Lorenzen EL, Taylor CW, Maraldo M, Nielsen MH, Offersen BV, Andersen MR, O’Dwyer D, Larsen L, Duxbury S, Jhitta B, Darby SC, Ewertz M, Brink C (2013) Inter-observer variation in delineation of the heart and left anterior descending coronary artery in radiotherapy for breast cancer: a multi-centre study from Denmark and the UK. Radiother Oncol 108(2):254–258CrossRefGoogle Scholar
  11. 11.
    Hooning MJ, Botma A, Aleman BM et al (2007) Long-term risk of cardiovascular disease in 10-year survivors of breast cancer. J Natl Cancer Inst 99(5):365–375CrossRefGoogle Scholar
  12. 12.
    Karha J, Murphy SA, Kirtane AJ, de Lemos JA, Aroesty JM, Cannon CP, Antman EM, Braunwald E, Gibson CM, TIMI Study Group (2003) Evaluation of the association of proximal coronary culprit artery lesion location with clinical outcomes in acute myocardial infarction. Am J Cardiol 92:913–918CrossRefGoogle Scholar
  13. 13.
    Bergom C, Currey A, Desai N, Tai A, Strauss JB (2018) Deep inspiration breath hold: techniques and advantages for cardiac sparing during breast cancer irradiation. Front Oncol 8:87CrossRefGoogle Scholar
  14. 14.
    Hayden AJ, Rains M, Tiver K (2012) Deep inspiration breath hold technique reduces heart dose from radiotherapy for left-sided breast cancer. J Med Imaging Radiat Oncol 56(4):464–472CrossRefGoogle Scholar
  15. 15.
    Swanson T, Grills IS, Ye H, Entwistle A, Teahan M, Letts N, Yan D, Duquette J, Vicini FA (2013) Six-year experience routinely using moderate deep inspiration breath-hold 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 36(1):24–30CrossRefGoogle Scholar
  16. 16.
    Taylor CW, McGale P, Povall JM, Thomas E, Kumar S, Dodwell D, Darby SC (2009 Mar 15) Estimating cardiac exposure from breast cancer radiotherapy in clinical practice. Int J Radiat Oncol Biol Phys 73(4):1061–1068CrossRefGoogle Scholar
  17. 17.
    Nissen HD, Appelt AL (2012) Improved heart, lung and target dose with deep inspiration breath hold in a large clinical series of breast cancer patients. Radiother Oncol 106(1):28–32CrossRefGoogle Scholar
  18. 18.
    Feng M, Moran JM, Koelling T, Chughtai A, Chan JL, Freedman L, Hayman JA, Jagsi R, Jolly S, Larouere J, Soriano J, Marsh R, Pierce LJ (2011) Development and validation of a heart atlas to study cardiac exposure to radiation following treatment for breast cancer. Int J Radiat Oncol Biol Phys 79(1):10–18CrossRefGoogle Scholar
  19. 19.
    Radiation Therapy Oncology Group: RTOG Breast Cancer Atlas, Online available from:
  20. 20.
    Early Breast Cancer Trialists’ Collaborative Group (2000) Favourable and unfavourable effects on long-term survival of radiotherapy for early breast cancer: an overview of the randomised trials. Lancet 355:1757–1770CrossRefGoogle Scholar
  21. 21.
    Hooning MJ, Aleman BM, van Rosmalen AJ, Kuenen MA, Klijn JG, van Leeuwen FE (2006) Cause-specific mortality in long-term survivors of breast cancer: a 25-year follow-up study. Int J Radiat Oncol Biol Phys 64:1081–1091CrossRefGoogle Scholar
  22. 22.
    Vikström J, Hjelstuen MH, Mjaaland I, Dybvik KI (2011) Cardiac and pulmonary dose reduction for tangentially irradiated breast cancer, utilizing deep inspiration breath-hold with audio-visual guidance, without compromising target coverage. Acta Oncol 50:42–50CrossRefGoogle Scholar
  23. 23.
    Taylor C, Correa C, Duane FK, Aznar MC, Anderson SJ, Bergh J, Dodwell D, Ewertz M, Gray R, Jagsi R, Pierce L, Pritchard KI, Swain S, Wang Z, Wang Y, Whelan T, Peto R, McGale P, for the Early Breast Cancer Trialists’ Collaborative Group (2017) Estimating the risks of breast cancer radiotherapy: evidence from modern radiation doses to the lungs and heart and from previous randomized trials. J Clin Oncol 35:1641–1649CrossRefGoogle Scholar
  24. 24.
    Schuster EH, Griffith LS, Bulkley BH (1981) Preponderance of acute proximal left anterior descending coronary arterial lesions in fatal myocardial infarction: a clinicopathologic study. Am J Cardiol 47:1189–1196CrossRefGoogle Scholar
  25. 25.
    Nilsson G, Holmberg L, Garmo H, Duvernoy O, Sjögren I, Lagerqvist B, Blomqvist C (2012) Distribution of coronary artery stenosis after radiation for breast cancer. J Clin Oncol 30(4):380–386CrossRefGoogle Scholar
  26. 26.
    Jagsi R, Griffith KA, Koelling T, Roberts R, Pierce LJ (2007) Rates of myocardial infarction and coronary artery disease and risk factors in patients treated with radiation therapy for early-stage breast cancer. Cancer 109(4):650–657CrossRefGoogle Scholar
  27. 27.
    Nilsson G, Witt Nyström P, Isacsson U, Garmo H, Duvernoy O, Sjögren I, Lagerqvist B, Holmberg L, Blomqvist C (2016) Radiation dose distribution in coronary arteries in breast cancer radiotherapy. Acta Oncol (Madr) 55(8):959–963CrossRefGoogle Scholar
  28. 28.
    Nielsen MH, Berg M, Pedersen AN, Andersen K, Glavicic V, Jakobsen EH, Jensen I, Josipovic M, Lorenzen EL, Nielsen HM, Stenbygaard L, Thomsen MS, Vallentin S, Zimmermann S, Offersen BV, on behalf of the Danish Breast Cancer Cooperative Group Radiotherapy Committee (2013) Danish Breast Cancer Cooperative Group Radiotherapy Committee. Delineation of target volumes and organs at risk in adjuvant radiotherapy of early breast cancer: national guidelines and contouring atlas by the Danish Breast Cancer Cooperative Group. Acta Oncol 52(4):703–710CrossRefGoogle Scholar
  29. 29.
    Drost L, Yee C, Lam H, Zhang L, Wronski M, McCann C, Lee J, Vesprini D, Leung E, Chow E (2018) A systematic review of heart dose in breast radiotherapy. Clin Breast Cancer 18(5):e819–e824CrossRefGoogle Scholar
  30. 30.
    Hurkmans CW, Cho BCJ, Damen E, Zijp L, Mijnheer BJ (2002) Reduction of cardiac and lung complication probabilities after breast irradiation using conformal radiotherapy with or without intensity modulation. Radiother Oncol 62:163–171CrossRefGoogle Scholar
  31. 31.
    Lawler G, Leech M (2017) Dose sparing potential of deep inspiration breath-hold technique for left breast cancer radiotherapy organs-at-risk. Anticancer Res 37(2):883–890CrossRefGoogle Scholar
  32. 32.
    Willner J, Jost A, Baier K, Flentje M (2003) A little to a lot or a lot to a little? An analysis of pneumonitis risk from dose-volume histogram parameters of the lung in patients with lung cancer treated with 3-D conformal radiotherapy. Strahlenther Onkol 179(8):548–556Google Scholar
  33. 33.
    Marks LB, Bentzen SM, Deasy JO, Kong FM, Bradley JD, Vogelius IS, El Naqa I, Hubbs JL, Lebesque JV, Timmerman RD, Martel MK, Jackson A (2010) Radiation dose-volume effects in the lung. Int J Radiat Oncol Biol Phys 76(3 Suppl):S70–S76CrossRefGoogle Scholar
  34. 34.
    Lastrucci L, Borghesi S, Bertocci S, Gasperi C, Rampini A, Buonfrate G, Pernici P, De Majo R, Gennari PG (2017) Advantage of deep inspiration breath hold in left-sided breast cancer patients treated with 3D conformal radiotherapy. Tumori. 103(1):72–75CrossRefGoogle Scholar
  35. 35.
    Zagar TM, Kaidar-Person O, Tang X et al (2018) Utility of deep inspiration breath hold for left-sided breast radiation therapy in preventing early cardiac perfusion defects: a prospective study. Int J Radiat Oncol Biol Phys 97:903–909CrossRefGoogle Scholar
  36. 36.
    Zellars R, Bravo PE, Tryggestad E et al (2018) SPECT analysis of cardiac perfusion changes after whole-breast/chest wall radiation therapy with or without active breathing coordinator: results of a randomized phase 3 trial. Int J Radiat Oncol Biol Phys 88:778–785Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Radiation OncologyFondazione Istituto Oncologico del MediterraneoCataniaItaly
  2. 2.REM RadioterapiaCataniaItaly

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