Mini Research Proposal: Limiting dose to heart and lungs using

prone positioning with deep inspiration breath hold (DIBH) for

breast irradiation

Cassidy A Tigner, Student Therapist

Introduction & Hypothesis

Breast cancer is the most prevalent cancer in women. Because it is so common, there
was much research for the development of the best techniques and innovative technology. One
of the biggest issues with breast treatments today is limiting dose to the lung and heart, while
also giving an intense and accurate dose to the breast tumor and bed. The tolerance dose for the
whole heart is 4000cGy and for the whole lung is 1750cGy. According to ScienceDirect, In left-
sided breast cancer, mean heart dose averaged over all 398 regimens reported in 149 studies from
28 countries was 5.4 Gy.1 The more dose the heart gets, the more toxicity it will have and
potential for heart disease and other heart defects in the future increases. A few modifications
have been made to help reduce the dose to the heart and lungs. One modification to limit the
dose is to lay the patient in prone position. The patient would lay on their stomach, and a cut-out
is made into the board for the breast to fall into. The breast tissue will lie naturally in the cut-out
therefore bringing the breast tissue farther away from the chest wall, lung and heart. Another
modification would be a deep inspiration breath hold (DIBH). Using DIBH, the patient exhales
completely, inhales and holds their breath. When inhaling, the breast tissue is pushed away from
the chest wall, lung and heart. The DIBH makes it easier to target only the breast tissue and limit
the dose to the critical structures underneath. Today, treatment plans do not use these two
concepts together. This is a proposal to use prone positioning and DIBH concurrently while
giving a breast cancer radiation treatment. Using both of these modifications should enhance the
treatment and lower the dose to the heart and lungs. Although some patients may not be capable
of laying in the prone position, and some may be incapable of holding their breath for a long
time, I believe there will be patients that are able to do both of these modifications to make for
the most efficient treatment. If my hypothesis is correct, my critical prediction is that the dose to
the heart and lungs will be lower using prone positioning and DIBH together than from these
single modifications being used alone.

Literature Review
McKinnies and Collins wrote a double blind peer reviewed article of the advantages of
using the prone position to lower the dose to critical structures. The data was found using a
double blind experiment, there should be no patient or experimenter bias. The data found in this
experiment should not be biased because it is facts based on each individual treatment technique.
The researchers took a total of 25 patients, 11 being treated in the supine position and 14 in the
prone position. The authors of this article found that the dose to the lung in the supine position
received 10.9% of the total dose delivered and the prone position only received 1.5% out of the
total dose (see Figure 1).2 The average total dose for a breast treatment is between 5000cGy-
5400cGy, so treating in the prone position could reduce the lung dose by 470cGy-508cGy to the
lung.

Olson also wrote a double blind peer reviewed article of the advantages of using the
prone position to lower the dose to critical structures. Not only did the researcher find that the
prone position will reduce late toxicities by greatly reducing the amount of dose to critical
organs, namely the ipsilateral lung by 4.04 Gy to 5.43 Gy, but it will also help decrease the
amount of skin reaction due to less skin fold.3 When the prone position is reproducible, the breast
will fall into the cut-out and the skin should not touch the abdomen or the ipsilateral arm. The
arms are usually up, holding on to a post with a vacbag to keep the shape; this keeps the arm
from making a crease with the breast tissue (see Figure 2). This article and the one listed above
agree with one another and also have approximately the same range of data for sparing the
critical structures.

Formenti et al. also wrote a study on the superiority of prone positioning over supine
positioning for breast cancer radiation treatments. This source is only a research letter and may
not be as viable as the two sources listed above. I chose to still include it in this paper because I
felt it shared accurate information pertaining to the prone position and an alternate look on the
subject. Instead of this source also researching the amount of dose to the critical structures, it
examined the volumes of critical structures in both the supine and prone position treatment
fields. It was shown that the volumes for lung tissue in treatment fields in the prone position
were reduced by at least 90% compared to the supine position. 85% of patients also showed
reduction in heart tissue in the treatment fields, but 15 % of the left sided breast cancer patients
had a lower heart volume when treated in the supine position.4

Yeung et al. researched the use of DIBH to limit dose to the heart and the lungs during
breast cancer radiation treatments. This article had a study of 20 breast cancer patients that were
split into two cohort studies: eleven for whole breast radiotherapy (WBRT) and nine for breast or
chest wall radiotherapy plus regional nodal irradiation, including the IMC and supraclavicular
nodes (B/CWRT + RNI).5 All patients under the WBRT cohort were able to have the heart dose
under 400cGy with DIBH and 56% of the B/CWRT + RNI cohort were able to stay under
400cGy.5 I did not like this article as well as others and felt that the study needed to include a
higher amount of participants in the research study to provide an accurate depiction of patients
overall.

Vikstrom et al. conducted an experiment beginning with 17 patients. Of these patients,

twelve patients had left sided breast cancer and five had right sided cancer. All of the patients had
to be capable of holding their breath for 15-20 seconds in order to perform in the experiment.
The total dose the heart received for a free breathing treatment was about 307cGy and was
decreased to 107cGy for patients that used the DIBH technique in the supine position. This
article also pointed out that a downfall to DIBH is that it may cause a higher dose to the
contralateral breast. In this experiment there was a slight change of the contralateral breast
receiving only 3.4% of the total dose during free breathing and 3.7% during DIBH treatments.6 I
believe the small deviation in contralateral breast dose is negligible compared to the decrease in
cardiac dose using DIBH.

Swanson et al. researched DIBH versus free breathing of 99 left sided breast cancer
patients. Instead of having an experiment between both, they only had patients that were
receiving treatment using DIBH. Dosimetrists took CT scans with DIBH and with free breathing
to produce the contours and dose pattern to each patient. In 87 of these patients, DIBH was found
to be better than free breathing. Overall, DIBH reduced the toxicity of the heart from radiation by
about 40%. Also, there was a reduction in heart dose by about 13%.7 Although DIBH was great
for reducing the dose and toxicity to the heart, it barely did anything for the lung. This is
something that should be addressed so we can decrease the dose to both of these critical
structures drastically.
Figure 1: Prone vs. supine dose to critical structures2

Figure 2: supine vs prone breast tissue positioning8

Methods

In order to test my hypothesis, an experiment must be done. I would have three separate
treatment groups of patients: one group prone position, supine position using DIBH and prone
position using DIBH. There must be three groups to receive a true measure between the different
types of treatment methods. All patients in this protocol must have Stage 1 or Stage 2 breast
cancer in only one intact breast. They also must be tested before treatment begins if they are able
to hold their breath or lay in the prone position. Those who can only do one of these procedures
will be manipulated into the single group. Patients that are capable of doing both procedures, at
the same time, will be in the group combining the two procedures. My intentions are to have 50
patients in each group. Each patient will receive around 5000cGy to their breast in 30 treatments.
While the patients have the CT simulation prior to treatment, the dosimetrist will look at the dose
distribution in order to see which treatment had the best outcome with sparing the lung and heart.
Also, after the treatment is complete, the patients in this experiment will have a check-up at one
month, six months, one year and five years to determine their cardiac toxicity and functioning
levels due to radiation therapy. This experiment will take a while to have a final documentation
to put an effort towards proving the best way to treat a breast cancer patient.

Possible Results

It was shown in the sources listed above that the dose to the critical structures were
decreased in both prone positioning and DIBH. Prone positioning decreased the dose to lung
tissue by about 9% compared to supine positioning. It is controversial for the reduction of dose
the heart received in the prone position for left sided breast cancer treatments, but for right sided
patients the prone position reduced the dose to the heart. In the prone position, it reduced the
dose and toxicity to the lung. DIBH also decreased the dose compared to free breathing. DIBH
mostly accounted for the reduction in heart toxicity. I believe that if my hypothesis is correct, the
signs of heart toxicity and disease will be decreased by an abundant amount, so abundant that it
will fully be put into practice. Also, the methods of my experiment would be used again to prove
my critical prediction.

If my hypothesis turns out to be false, the prone positioning with DIBH will not be used
and will not have a better outcome than the previous modification for treatment. This will show
that the heart and/or lungs actually received more dose than what a different treatment setup
would. Also, if my hypothesis fails, there must be further testing to find a treatment technique
that can reduce the dose to the heart and lungs.
References
1. International Journal of Radiation Oncology. Redjournalorg. 2016. Available at:
http://www.redjournal.org/article/S0360-3016(15)03103-X/abstract?cc=y=. Accessed July 18,
2016.
2. McKinnies RCollins K. Comparing Critical Structure Dose: Prone vs Supine Breast
Treatments. Radiation Therapist, Fall 2011. 2016;20(2):103-107.
3. Olson K. Improving Treatment Outcomes of Breast Radiation Therapy: The Prone Position.
Radiation Therapist, Spring 2014. 2016;23(1):21-26.
4. Formenti S, DeWyngaert J, Jozsef G, Goldberg J. Prone vs Supine Positioning for Breast
Cancer Radiotherapy. JAMA. 2012;308(9):861. doi:10.1001/2012.jama.10759.
5.Yeung R, Conroy L, Phan T, et al. Cardiac dose reduction with deep inspiration breath hold for
left-sided breast cancer radiotherapy patients with and without regional nodal
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tangentially irradiated breast cancer, utilizing deep inspiration breath-hold with audio-visual
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2011;50(1):42-50 9p. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July
18, 2016.
7. Swanson T, Grills I, Ye H et al. 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. American Journal of Clinical
Oncology. 2013;36(1):24-30. doi:10.1097/coc.0b013e31823fe481.
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Ipswich, MA. Accessed December 14, 2007.