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A Case Study of DIBH to Spare Abdominal Organs at Risk for Renal Cell Carcinoma MR-
Guided Radiotherapy
Authors: Steven D. Yorio R.T.(R)(VI), Nishele Lenards, Ph.D., CMD, R.T.(R)(T), Ashley
Hunzeker, M.S., CMD, Ashley Fellows, M.S., CMD, R.T.(T)
Medical Dosimetry Program at the University of Wisconsin - La Crosse
Key Words: Renal cell carcinoma, MR-linac, OAR, DIBH, Magnetic Resonance-guided
radiotherapy
Introduction
Creating a radiation treatment plan that is both accurate and effective requires precision.
While it may appear like a simple task when analyzing a patient’s computed tomography
simulation (CT SIM) scan, traditional treatment methods such as 3D conformal, intensity
modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT) can fall
short in this regard due to organ motion and the inability to visualize it. The nuances of both
IMRT and VMAT treatments offer increased accuracy and dose conformality in treatment
planning over 3D conformal, but new modalities with real-time imaging have showed that
certain anatomy will move during treatment. Planning treatments on a retrospective simulation
CT scan does not always give an accurate depiction of dose distribution for organs in motion
such as the lungs, bowel, and kidneys. The proximity of some tumors to organs at risk (OAR) in
these high motion regions created the need for additional methods to make treatment successful
without the risk of additional toxicities. Magnetic Resonance-guided radiotherapy (MRgRT)
provides real-time imaging to characterize and track anatomical motion.1 The advent of MRgRT
has provided clinicians with the ability to visualize the extent of this motion during a course of
radiation treatment and has enabled them to utilize additional techniques to place anatomy in a
desirable location for each treatment.
Historically, deep inspiration breath hold (DIBH) is a technique used when treating a left
sided breast cancer with radiation therapy to reduce the risk of cardiac injury by creating a wider
separation between the chest wall and heart. It has been found that this can reduce the risk of
heart disease and coronary events which is estimated to increase 4–7% for each 1 Gray (Gy) in
mean heart dose, and there does not appear to be a minimum dose threshold below which there is
no risk of cardiac events.2 Typically, this technique is not used for treatment of lesions other than
those located within the left breast, although, DIBH has recently been utilized when treating
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lesions within close proximity to the diaphragm, such as the kidneys, to create a wider distance
between the tumor and the radiosensitive OAR.
Renal cell carcinoma (RCC) is the most lethal of urologic malignancies, accounting for
an estimated 36,000 new cases of carcinoma and 12,000 deaths in 2005. Nephrectomy is the
usual treatment; however, RCC recurs post nephrectomy in 20% to 40% of patients with
clinically localized disease.3 Renal cell carcinoma has traditionally been regarded as a
radioresistant tumor based on preclinical data and negative clinical trials using conventional
fractionated radiotherapy. However, there is emerging evidence that radiotherapy delivered in
fewer fractions with high single-fraction and total doses may overcome RCC radioresistance.4
Respiration-induced motion of the kidneys has been a major challenge of renal
radiotherapy due to tumor displacement outside the PTV with diaphragmic contraction and
relaxation. In a particular case, an alternative treatment was required to evaluate the use of DIBH
in congruence with MRgRT for limiting dose to healthy OAR and successfully treat RCC in the
post-operative tumor bed. This adaptive treatment was required due to the concern of
conventional methods increasing radiation toxicity to the surrounding structures without the use
of motion management and real-time imaging. The purpose of this case study was to examine the
effectiveness of DIBH in sparing radiation dose to colon and small bowel during MRLinac
treatment of right sided RCC. The goals of treatment planning were to reduce radiation dose to
colon and small bowel during RCC treatment with MRgRT and DIBH (Case Study Goals 1 and
2, respectively).
Case Description
Patient Selection & Setup
The deciding factors for this patient’s treatment included positive renal cell carcinoma,
the ability to perform DIBH, and an absence of any pathology or implant that would prevent a
safe treatment with MR-linac (i.e. pacemaker, defibrillator, etc). This study regards a 73-year-old
male with metastatic RCC. The disease was controlled by dual immunotherapy, but the patient
developed tumor progression in the operative bed in the right renal fossa. The tumor bed was
directly abutting the colon which was deemed problematic for treatment planning.
CT simulation was performed using a Siemens Somatom simulator. The patient was
placed headfirst supine with their arms raised above their head on a customized arm board for
immobilization with a bolster beneath his knees for comfort (Figure 1). The simulation scan was
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performed using 4DCT. When acquiring a retrospective 4D data set, the respiratory cycle is split
into phases, usually 10 phases per breathing cycle, and the slices are sorted by phases. Each
phase is then reconstructed into a 3D data set. The 4D motion can then be observed by looping
through the 3D images for each phase. In this way the entire range of motion can be visualized.1
Typical gated treatments utilize the mid position of the 4DCT scan, which places the
location of the tumor at the 40%, 50%, and 60% of the respiratory cycle. Along with the 4DCT,
two additional CT simulation scans were performed, one at the point of deepest inspiration and
one at the point of deepest expiration to evaluate change in tumor position (Figure 2). For this
patient, the tumor was farthest away from OAR at the point of deepest inspiration, making this
scan most useful for initial treatment planning. After practicing breath holds during simulation, it
was discovered that the patient was capable of DIBH for up to twenty-five seconds.
Target Delineation
After the acquisition of the deep inspiration CT scan, the physician and the dosimetrist
contoured structures around pertinent anatomy using MIM Maestro® contouring software. The
physician was responsible for contouring the gross tumor volume (GTV) directly around the
tumor bed and creating a one-centimeter (cm) expansion of this structure to generate the
planning target volume (PTV). The medical dosimetrist contoured all OAR which consisted of
the liver, gallbladder, right and left lungs, heart, left kidney, stomach, spinal cord, aorta,
duodenum, esophagus, ribs, small bowel, and colon.
Treatment Planning
A preliminary treatment plan was compiled on the DIBH CT scan to better understand
the dose distribution throughout the patient’s anatomy. This treatment plan was created using
Monaco software version 5.51.10 which is synonymous to the planning software used for daily
adaptive planning MR scans for each fractional treatment with the 1.5 Tesla Elekta Unity MR-
linac. The physician decided to utilize stereotactic body radiation therapy (SBRT) with a
prescribed dose of 50 Gy in five fractions to the PTV, and dose constraints for OAR where
predominantly focused on limiting dose to the colon (D0.03cm3<3000cGy), small bowel
(D0.03cm3<3000cGy), and left kidney (D0.03cm3<4513cGy) (Table 1). 6MV photons were used
for this treatment.
To ensure the patient was able to allow for full inspiration prior to holding their breath,
real time imaging was required during treatment for accurate tumor localization. This objective
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was achieved with the use of the Elekta Unity with step-and-shoot IMRT. Currently, step-and-
shoot is the only delivery technique for IMRT available on Unity, and the treatments are
performed using the dynamic multileaf collimator (DMLC) technique.4 The final treatment plan
consisted of 8 beams and 40 segments.
Patient Treatment
Prior to delivery of each fractional dose, a series of scans were taken to optimize
visibility of patient anatomy as it presents on the day of treatment. Repeat scans for cine images
at the point of DIBH were performed to reduce parallel imaging reconstruction artifacts. MR
scans were performed using the mDixion series, which exploits the fact that water and fat
molecules precess at different rates. As such, over time, they will alternate between being in-
phase (IP) and opposed-phase (OP). Acquiring both in-phase and opposed-phase images
simultaneously allows the images to be combined mathematically in two ways which result in a
total of 4 sequences5 (Figure 3):
1. in-phase =  (water + fat)
2. opposed-phase = (water - fat) 
3. fat only =  in-phase - opposed phase = (water + fat) - (water - fat) 
4. water only = in-phase + opposed phase = (water + fat) + (water - fat) – used as a
reference scan.

Each treatment fraction starts with the acquisition of an MRI scan. The pre-treatment CT,
structure contours, and plan combined with the MRI are used as input to adapt the plan for each
specific fraction. Performing plan adaptation on the system can be performed through two
different workflows using the Monaco TPS: adapt to position (ATP) and adapt to shape (ATS).
For ATP no daily delineation is needed nor possible, only the (isocenter) position is updated in
the pre-treatment CT, while for ATS the daily MRI can be re-contoured to be used for adapting
the treatment plan.3 The ability to contour and localize a tumor volume as it presents during
treatment is a milestone in the field of radiation therapy.
The adaptation strategy utilized for this case was adapt to shape (ATS), in which each
structure must be recontoured based on the daily MR scan. To expediate the process, the
radiation therapist was responsible for all non-deforming OAR contours, the physician contoured
the targets, and the physicist contoured the air, bone, and external patient outline. Structures for
motion monitoring consisted of the PTV and colon planned organ at risk volume (PRV) and
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were drawn to allow for better interpretation of when the target was settled within the PTV
volume upon DIBH (Figure 4).

Excessive teamwork was necessary in order to place the tumor within the proper structure
when administering DIBH. To deliver treatment with DIBH, manual sequencing groups had to
be used to allow the patient to rest between breath holds. The planning system calculated that
there would be seven breath holds per beam.
Motion monitoring was performed using a single sagittal plan cine with solely the colon
OAR structure and PTV being visible (Figure 5). The process of delivering DIBH required the
radiation therapist (RT) to give breath hold instructions and turn the beam on only when the
target anatomy settled into position. The RT manually paused the beam at the end of each breath
hold or if the anatomy began to drift out of the PTV contour.
Plan Analysis and Evaluation
Each fraction of the adaptive MRgRT plan successfully met all OAR constraints as were
defined by the physician. A dose volume histogram (DVH) was used for evaluation of the doses
received by the target and OAR (Figure 6). Even though in daily adaptive plans OAR doses
varied from the initial plan by 50 centigray (cGy) for some structures, all organs were within the
acceptable dose limits. Both goals of this case study were achieved as dose was spared to the
colon and small bowel while successfully treating the RCC tumor bed. The dosimetric criteria
for the colon of D0.03cm3<3000cGy and D20cm3<1500cGy were met as the output for these
constraints came to 2015.5cGy and 992.6cGy respectively. Similarly, the dosimetric criteria for
small bowel was met as well with constraints being the same as the colon and came to 2015cGy
and 1001cGy respectively. The prescribing physician considered the resulting doses to both
structures to be acceptable in congruence with the successful RCC treatment.
Utilization of the single sagittal plan MR cine was deemed beneficial for tumor
placement within the PTV by means of DIBH for treatment. Throughout all five fractions the
patient experienced no acute side effects from the treatment itself. The only adverse event that
was logged during this MRgRT was the development of colitis, although, this was found to be
the cause of the patient’s adjuvant immunotherapy. The condition was easily controlled with the
use of steroids.
After receiving follow-up imaging within a weeks of treatment completion, the positron
emission tomography (PET) and CT scans showed a complete treatment response in the renal
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fossa with no signs of disease progression. Since the MRgRT treatment, the patient returned to
radiation oncology for an additional SBRT treatment to a metastatic lesion within the right iliac
crest. After successful treatment via conventional SBRT to the iliac lesion, the patient has
concluded all courses of immunotherapy and remains without any clear evidence of disease
progression.
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References

1. Corradini S, Alongi F, Andratschke N, et al. MR-guidance in clinical reality: current

treatment challenges and future perspectives. Radiother Oncol. 2019;14(1).
http://doi.org/10.1186/s13014-019-1308-y
2. Bergom C, Currey A, Desai N, et al. Deep inspiration breath hold: techniques and
advantages for cardiac sparing during breast cancer irradiation. Front Oncol. 2018.
http://doi.org/10.3389/fonc.2018.00087

3. Winkel D, Bol GH, Kroon PS, et al. Adaptive radiotherapy: The Elekta Unity MR-linac
concept. Clinic and Trans Radiat Oncol. 2019;18:54-59.
http://doi.org/10.1016/j.ctro.2019.04.001
4. Rühle A, Andratschke N, Siva S, et al. Is there a role for stereotactic radiotherapy in the
treatment of renal cell carcinoma? Radiother Oncol. 2019;18:104-112.
http://doi.org/10.1016/j.ctro.2019.04.012

5. Ding S, Li Y, Liu H, et al. Comparison of intensity modulated radiotherapy treatment

plans between 1.5T MR-Linac and conventional linac. Technol Cancer Res Treat.
2021;20:153303382098587. http://doi.org/10.1177/1533033820985871
6. Leyendecker JR, Brown JJ, Merkle EM, et al. Practical guide to abdominal and pelvic
MRI. LWW. (2010) ISBN:1605471445.
7. Chin A, Lam J, Figlin R, et al. Surveillance strategies for renal cell carcinoma patients
following nephrectomy. Rev Urol. December 2016.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1471767/. Accessed May 19, 2021.
8. Naumann P, Batista V, Farnia B, et al. Feasibility of optical surface-guidance for position
verification and monitoring of stereotactic body radiotherapy in deep-inspiration breath-
hold. Front Oncol. 2020;10. http://doi.org/10.3389/fonc.2020.573279
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Figures

Figure 1. Treatment table for Elekta Unity and patient set up with an adjustable arm board for
comfort.

Mid Position

Deep
Expiration

Deep
Inspiration
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Figure 2. Transverse, sagittal, and coronal images of CT scans using 4DCT, deep expiration
breath hold (DEBH), and deep inspiration breath hold (DIBH) for tumor location comparison.

Figure 3. Original scan MR scan (left)

compared to an optimized MR scan (right) to reduce parallel imaging reconstruction artifacts.

Figure 4. Sagittal view of the motion monitoring structures, PTV (green) + Colon planning
organ at risk volume (PRV) (purple).
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Figure 5. Motion monitored single frame of real time MR scan during treatment. Note placement
of tumor inside target contour during DIBH.

Figure 6. Axial, coronal, and sagittal views with DVH of planned dose distribution to target and
OAR.
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Tables

Table 1. Dose volume histogram statistics and dosimetric criteria for targets and all OAR.
Structure Dosimetric Criterion Actual Value Pass/Fail
PTV V5000cGy > 97% (-2%) 95% ✓
Liver-ITV D1226cc < 1500 cGy (+380 cGy) 74.8 cGy ✓
SpinalCord D0.03cc < 1710 cGy (+90 cGy) 1136.0 cGy ✓
D1.2cc < 1235 cGy (+65 cGy) 1012.3 cGy ✓
Ribs D0.03cc < 4750 cGy (+2300 cGy) 3065.5 cGy ✓
D5cc < 4000 cGy (+2300 cGy) 587.3 cGy ✓
Aorta D0.03cc < 4500 cGy (+1800 cGy) 2113.5 cGy ✓
D10cc < 3900 cGy (+2400 cGy) 1325.4 cGy ✓
Bowel D0.03cc < 3000 cGy (+3300 cGy) 2015.5 cGy ✓
D20cc < 1500 cGy (+4800 cGy) 1001.0 cGy ✓
Chest wall D3cc < 6000 cGy (+300 cGy) 2441.4 cGy ✓
D30cc < 3000 cGy (+3300 cGy) 1782.2 cGy ✓
Colon D0.03cc < 3000 cGy (+3300 cGy) 2015.5 cGy ✓
D20cc < 1500 cGy (+4800 cGy) 992.6 cGy ✓
Duct_CommonBile D0.03cc < 4512 cGy (+238 cGy) 1864.5 cGy ✓
D0.3cc < 3600 cGy (+2700 cGy) 1670.5 cGy ✓
Duodenum D0.03cc < 3000 cGy (+3300 cGy) 352.5 cGy ✓
D10cc < 1500 cGy (+4800 cGy) 61.6 cGy ✓
Esophagus D0.03cc < 2400 cGy (+3900 cGy) 64.1 cGy ✓
D5cc < 1500 cGy (+4800 cGy) 50.2 cGy ✓
Gallbladder D0.03cc < 4500 cGy (+1800 cGy) 1533.5 cGy ✓
Heart D0.03cc < 3000 cGy (+3300 cGy) 53.2 cGy ✓
D15cc < 2400cGy (+3900 cGy) 42.6 cGy ✓
Kidney_L D0.03cc < 4513 cGy (+237 cGy) 136.5 cGy ✓
D35% < 1500 cGy (+150 cGy) 42.3 cGy ✓