Jonathan Gonzales

DOS 523 Treatment Planning in Med Dos

March 29, 2015
Conformal Terminology: Breathing Movement & Respiratory gating
Breathing movement. What is it? Breathing is the act of inhaling and filling our lungs with
oxygen to exhaling and releasing carbon dioxide. Our bodies continually need oxygen to carry
out the process of respiration. During inspiration, the pressure in our lungs is decreased and air
rushes in, our diaphragm contracts and moves down. As air fills the lungs the chest expands
anteriorly and laterally. During exhalation, the diaphragm will begin to relax and move up. The
chest will return back to resting position and move inward and carbon dioxide will then be
expelled out of the lungs through the mouth/nose. Examples of these motions can be visualized
on Image 1-3.

Image 1: Breathing movement.[1]

Image 2: Motion of the diaphram during inspiration (a) and direction of chest expansion during
inspiration (b).[2]

Image 3: Chest x-ray of inspiration vs. expiration.[3]

Breathing movement can pose difficulties when it comes to planning for radiation
treatments. Treatments of certain organs may require the consideration of accounting for such
movements due to respiration, for example: lung, liver, kidney, pancreas, and breast.[2] The
motion of these organs during respiration does not have any specific pattern that can be assumed
by a particular patient.[2] Instead, the motion of any of these organs has to be analyzed on a
patient to patient basis. To help monitor the movements of these organs a technique of respiratory
gating can be used.
There various methods to account for respiratory motion in radiotherapy. There are five
major categories: motion-encompassing methods, respiratory-gating techniques, breath-hold
techniques, forced shallow-breathing techniques, and respiration-synchronized techniques. For
this discussion, I will be focusing on the respiratory-gating technique.
Respiratory-gating is the real-time tracking of breathing movement during the
administration of radiation during both the imaging and treatment process. Gate is the word
referring to a particular portion of a patients breathing cycle.[2] During a CT scan, patient
breathing motion can be tracked using respiratory gating equipment, there are certain methods of
obtaining the pattern of a patients respiration: motion sensory camera, tracked external fiducial
markers places on the abdomen, and or a pressure sensitive gating belt that can be wrapped
around a patients abdomen.[2] All these equipments can monitor a patients breath and can aide
in understand a patients normal breathing cycle by visualizing the pattern in waveform. Being
able to record a patients breathing pattern allows the images to be acquired more specifically to

a desired phase. Gated CT scans are longer than non-gated scans because they are acquiring
images from many the various phases of a patients breathing cycle. The dataset of a gated scan
allows both the physician and dosimetrist a better understanding how to best treat the patient. In
Image 4, you will see a comparison of a CT that is free breathing and a gated-CT that is shown
on expiration. The waveform of a patients exhalation would appear as, refer to Image 5.

Image 4: Lung CT that is free breathing (a) and a gated-CT that is shown on expiration. [2]

Image 5: Waveform images acquired during a patients expiration. [4]

Simply, respiratory gating is the monitoring of patient breathing movement during either
a CT scan or during a patients treatment. Gated images are effective for removing artifact,
provided that the patient has a regular breathing pattern and it can also offer a clearer image for
tumor and OR definition. Being able to see not only the motion of the target but also the
surrounding OR allows the dosimetrist and radiation oncologist a better understanding of how to
define volumes and determination of treatment technigue. One could also use the gated

information to determine if a patient should be treated with either free breathing or if a breath
hold technique could be employed.

References
1. Poole N. The Breath Part One: Basic Breath Anatomy. Blog 889 Website.
http://889yoga.com/blog/yoga-movement/the-breath-part-one-basic-breath-anatomy/.
Accessed March 26, 2015.
2. Keall PJ, Mageras GS, Balter JM, et al. AAPM TG 76: The Management of Respiratory
Motion in Radiation Oncology. Med Phys. 33, 3874.
http://dx.doi.org/10.1118/1.2349696

3. Jain S. Interpretation of normal chest X-Rays [Powerpoint]. Department of Radio

Diagnosis at MGM Hospital. March 2014.
4. Elster A. Respiratory Compensation. Wake Forest School of Medicine Website http://mriq.com/respiratory-comp.html. Accessed March 26, 2015