1

Minimizing dose to the heart, left anterior descending artery, and lungs in whole breast
irradiation by reducing interleaf transmission on Elekta linear accelerators
Shelby Hall BS, RT(T); Makelle Barski BS, RT(T); Madeline Doberstein BS, RT(T); Thomas J.
Quinn, MD; Ashley Hunzeker, MS, CMD; Nishele Lenards PhD, CMD, RT(R)(T), FAAMD;
Alyssa Olson, MS, RT(T), CMD
Medical Dosimetry Program at the University of Wisconsin-La Crosse, WI
ABSTRACT
Introduction
The goal of radiation therapy treatment is to provide adequate coverage to the tumor
while sparing surrounding normal tissue and nearby critical structures. In tangential breast
treatment, dose to the heart, lungs, and other critical structures can cause serious side effects such
as ischemic heart disease, congestive heart failure, and radiation pneumonitis.1 A current study
has mentioned a limit of approximately 5 Gy for the mean dose to the heart, however, there is
still a risk for a major coronary event below this dose.2 According to Darby et al, the risk of a
major coronary event increases linearly as the mean heart dose increases and does not show any
threshold below which there is no risk.3 Specifically, it was found that for each Gy the heart
receives, the risk for ischemic heart disease increases on average by 7.4%. Due to the risk of
ischemic heart disease, many techniques have been developed that reduce dose to critical
structures in breast treatments, such as intensity-modulated radiation therapy (IMRT), prone
breast radiotherapy, deep inspiration breath-hold, partial breast irradiation, and proton beam
therapy.4 In a systematic meta-analysis of studies (2003-2013) on mean heart doses for the
treatment of left-sided breast cancer, it was shown that the supine position, with no breath hold,
was the most common position for treatment.5 While the techniques listed above are certainly
advantageous to the patient, the heart can still receive 1-5 Gy in these treatments.3,4
A collimator angle of 0° is often used in tangential breast treatments. If collimator
rotations are utilized, the collimator is often rotated parallel to the chest wall to help limit dose to
the lung. However, these commonly used angles could be yielding more interleaf transmission
than necessary when using an Elekta linear accelerator. The collimation design of an Elekta
linear accelerator is that of a single set of diaphragms that move perpendicular to the multileaf
collimator (MLC).6 A study of interleaf leakage on an Elekta Synergy machine showed that there
was an average interleaf leakage of 1.9% for a 6 MV photon beam.7 Chen et al compared doses
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to critical structures in IMRT lung cases with various MLC transmission values.8 The lowest
transmission value showed a decrease in the doses to the lung, which could reduce the chances
for radiation pneumonitis. In a similar study by Chapek et al, dose to the rectal wall in prostate
treatment plans was shown to decrease with an optimal collimator angle meant to minimize
transmission through MLC leaves.9 On the contrary, another study regarding parotid gland
irradiation and dose to the contralateral parotid gland and cochleae showed that there was no
difference in dose regardless of collimator angle.10
In an exhaustive literature review, the researchers were not able to locate similar studies
using an optimal collimator angle to reduce MLC interleaf transmission and limit dose to critical
structures in breast cancer treatment. The aim of this retrospective study was to determine if
reducing interleaf transmission with an additional collimator rotation of 90°, in standard right
and left whole breast irradiation, will reduce the dose to critical structures while maintaining
adequate coverage of the target volume.
Methods and Materials
Patient Selection
Sixty-five patients from a single institution were chosen for this study. The inclusion
criteria were female patients with Stage 0, I, or II breast cancer, treated using tangential fields in
the supine position. Patients with lymph node involvement were excluded from this study. The
patient data was collected retrospectively to include 35 patients with left-sided breast cancer and
30 patients with right-sided breast cancer. Of the patients selected, 15 patients had Stage 0 ductal
carcinoma in situ (DCIS), 43 patients had invasive ductal carcinoma (IDC) Stages IA-IIB, 6
patients had invasive lobular carcinoma (ILC) Stages IA-IB, and 1 patient had invasive mucinous
Stage IIA. All patients were prescribed a dose of 42.56 Gy in 16 fractions with a curative intent.
Any dose from a boost was not considered in the final plan comparison due to variations in boost
planning methods used at the institution.
Each patient was simulated using a Philips CT scanner. The patients were positioned
head-first supine with both arms above the head (Figure 1). An upper body alpha cradle was
created to reproduce the arm position daily. Radio-opaque markers were placed at the superior,
inferior, medial and lateral borders of the treatment area by the physician. Thirty patients were
simulated using a deep inspiration breath-hold technique, and 35 patients were simulated free-
breathing. Each scan was obtained using a 3 mm slice thickness from the inferior aspect of the
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mandible superiorly to 5 cm below the breast tissue inferiorly. The scan was then exported to the
Pinnacle (Version 14.0) treatment planning system (TPS).
Contours
The CT scan obtained and imported from CT simulation was used for the contouring of
normal structures and target volume delineation. The clinical target volume of the surgical bed
(CTVsb) was contoured manually by the physician. According to department protocols, the
planning target volumes (PTVs) were defined using the tangential fields (further discussed in
treatment planning). Coplanar tangent treatment fields were placed by physician and a breast
contour was created from the 50% isodose line (avoiding exterior of the body contour and the
lung). The breast contour was contracted 5 mm to create the evaluated planning target volume
(PTV_Eval).
The critical structures contoured in this study were the heart, left lung, right lung, left
anterior descending artery (LAD) and external body contour. The body contour was completed
using an auto contouring tool in Pinnacle (Version 14.0). Both lungs were contoured using an
auto-contouring tool in Pinnacle (Version 14.0) in a pulmonary window level following the
Radiation Therapy Oncology Group (RTOG) 1106 contouring atlas.11 The heart was contoured
manually by the physician or medical dosimetrist following the RTOG 1106 contouring atlas.
Lastly, the LAD was contoured manually by the physician or medical dosimetrist.
Treatment Planning
All 65 patients were planned by using an inverse-planned 3D conformal technique in the
Pinnacle (Version 14.0) TPS as described by Van Asselen.12 Dose calculations were performed
using the Collapsed Cone Convolution (CCC) algorithm. Pinnacle’s direct machine parameter
optimization (DMPO) was used to generate segmented fields. A combination of 6 MV, 10 MV,
and 18 MV were used depending on patient size and ability to meet planning objectives. All
patients were planned for treatment on an Elekta Synergy or Elekta Agility linear accelerator.
Both medial and lateral tangent fields were established by the physician. Open fields,
labeled “OpenMed” and “OpenLat,” were designed by the physician utilizing the superior and
inferior borders defined during simulation. The gantry angles varied but were designed to
encompass the entire breast while avoiding any entrance or exit dose to the contralateral breast
and limiting the amount of lung included. Beam edges were adjusted to be nondivergent
medially. Based on the physician's preference, MLC leaves may have been added and shaped by
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the physician for additional cardiac shielding. Open fields included 2 cm of flash on the breast
tissue anteriorly. The collimator angle for each field remained at 0 or was rotated such that
collimator jaw edge was parallel to the ipsilateral lung cavity to further decrease dose to the
critical structures (Figure 2A). Additionally, a couch rotation was used to reduce dose to the
underarm when necessary.
In order to obtain segmented fields, the medial and lateral fields and any corresponding
MLCs were copied and labeled “SegMed” and "SegLat.” Before optimization, the IMRT
parameters for OpenMed and OpenLat were set to “beam weight.” The beam weight setting in
Pinnacle finds the optimal weight between the 2 open fields. The IMRT parameters for SegMed
and SegLat were set to DMPO. Thus, during inverse optimization, the shape of the OpenMed
and OpenLat fields remained fixed as the weighting of each beam was optimized.
Simultaneously, the SegMed and SegLat fields were optimized to create and weight segmented
fields. After optimization was complete, the final plan appropriately weighted the open fields and
created segments to decrease hotspots for a homogeneous dose distribution. Plans were
optimized until the objectives were met using the dose constraints provided by the Michigan
Radiation Oncology Quality Consortium (MROQC) breast studies.13
Once the planning objectives were met, the plan was copied into a new trial. On the new
trial, the collimator on the OpenMed and OpenLat were rotated an additional 90° to allow the
MLC leaves to run vertically (Figure 2B). The collimator angle for the segmented fields
remained at the original position. These fields were re-calculated and the doses to the normal
structures and planning volumes were recorded for both trials.
Plan Comparison
The PTV_Eval and critical structures were compared between the 2 trials: no additional
collimator rotation trial and the additional 90° collimator rotation trial. The mean dose to the
heart was analyzed using dose constraints based on the MROQC studies. These constraints
included a mean dose to the heart of 1.2 Gy on a left breast plan, or 0.7 Gy on a right breast plan.
Other constraints that were analyzed included the maximum dose (Dmax) to the heart, and, for left
breast patients only, the LAD mean and LAD Dmax doses. The ipsilateral lung dose was analyzed
using the volume receiving 20 Gy (V20), volume receiving 10 Gy (V10), and volume receiving 5
Gy (V5) values. Finally, the PTV_Eval coverage was analyzed by the percent volume of
PTV_Eval that received 90% of the prescription dose (D90), the percent volume that received
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95% of the prescription dose (D95), and the percent volume that received 100% of the
prescription dose (D100). This information was then used to derive mean values and mean percent
differences from the data collected.
Statistical Analysis
Each plan was evaluated individually to collect data for this study. Prior to analysis, the
data was evaluated for normality graphically and statistically using Q-Q plots and the Shapiro-
Wilk test, respectively. The dosimetric data evaluated did not have a Gaussian distribution;
therefore, the non-parametric, related samples, Wilcoxon Signed Rank test (WSR) was used to
compare whether or not the median difference between the related samples is different from 0.
The WSR was performed on the following critical structure dosimetry: mean heart dose, heart
Dmax, mean LAD dose, LAD Dmax, mean lung dose, lung V20, lung V10, and lung V5. Likewise,
the WSR was performed for the PTV_Eval coverage, defined as the percent volume receiving
the following doses: D100, D95, and D90. The effect size (r) of collimator rotation was calculated
|𝑍|
as 𝑟 = , where Z is the standardized Z statistic and N is the number of pairs.14 Overall effect
√𝑁

size was evaluated per Cohen’s classification: <0.2 (small), 0.2-0.8 (medium), >0.8 (large).15 All
statistical analyses were performed using RStudio (v1.2.1335) and SPSS (v24, IBM). All
statistical analyses utilized 2-sided testing with P < 0.05 considered statistically significant. The
following R packages were used: ggpubr and ggplot2. R markdown for all analyses are available
upon request.
Results
Collimator Rotation and Heart Dose
The median value of the mean heart dose utilizing the initial collimator angle was 0.83
Gy. When the collimator was rotated an additional 90°, the median value of the mean heart dose
was reduced to 0.62 Gy, corresponding to a median percent reduction of 25.3%. Similarly, the
median heart Dmax among patients with no collimator rotation was 5.2 Gy and 4.6 Gy with
collimator rotation, corresponding to a median percent reduction of 11.5%. The non-parametric,
related samples, WSR test revealed statistically significant differences for mean heart (Figure
4A) and Dmax (Figure 4B) doses (P < 0.001), with a large and medium effect size, respectively
(Table 1).
Collimator Rotation and LAD Dose
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For left sided breast patients in this study (n=35) the median value of the mean LAD dose
was 2.7 Gy before the additional collimator rotation, it was then reduced to a median value of 2.4
Gy with a 90° rotation, corresponding to a percent median reduction of 11.1% (Figure 5A). Of
note, the median value of the LAD Dmax was 4.7 Gy before the collimator rotation and increased
to 5 Gy after collimator rotation, corresponding to a percent median increase of 6% (Figure 5B).
Nevertheless, the WSR test revealed a majority of plans had reduced mean (34 vs. 1 pairs, P <
0.001) and Dmax (30 vs. 5 pairs, P < 0.001) LAD doses. This corresponds to a large and medium
effect size, respectively (Table 1).
Collimator Rotation and Lung Dose
Prior to collimator rotation, the median value of the mean lung dose was 4.4 Gy and this
was reduced to 4.2 Gy following 90° collimator rotation, corresponding to a percent median
reduction of 4.5% (Figure 6A). Similarly, there was percent median reduction of 2.7%, 5.1%,
and 6.1% for the percent volume of ipsilateral lung receiving 20 Gy (V20), 10 Gy (V10), and 5 Gy
(V5) (Figure 6B-D). As depicted in Table 1, WSR revealed a statistically significant difference
between pairs for mean lung, V10, and V5 (P < 0.001) but not for V20 (P = 0.164).
Collimator Rotation and PTV_Eval Coverage
The PTV_Eval receiving 100% of the prescription dose was 88.7% prior to collimator
rotation and 88.2% after collimator rotation, corresponding to a clinically insignificant percent
median reduction of 0.56%. Similarly, the PTV_Eval receiving 95% of the prescription dose was
99.3% prior to collimator rotation and 99.2% after collimator rotation (percent median reduction
of 0.1%). Finally, the PTV_Eval receiving 90% of the prescription dose remained at 100%
before and after collimator rotation. WSR revealed no statistically significant difference between
the paired data for 100% coverage (P = 0.832). However, for 95% coverage, the number of pairs
with reduced coverage, compared to increased coverage, was statistically significant (36 vs. 23
pairs, P = 0.007). Likewise, for 90% coverage, the number of pairs with reduced coverage,
compared to increased coverage, was statistically significant (26 vs. 10 pairs, P = 0.016).
Discussion
Reducing dose to critical structures should not compromise dose to target volumes in
order to prevent recurrence or inadequate coverage to the tumor. In the current study, clinically
equivalent target volume coverage was confirmed, which demonstrated that the application of
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the additional 90° collimator rotation did not compromise PTV coverage. Additionally, nearly
identical isodose coverage to the PTV_Eval was shown between the 2 trials (Figure 6).
Chen et al suggested that lower MLC transmission could decrease dose to critical
structures,8 which was consistent with the findings of the current study. It was also suggested
that lower MLC transmission could be advantageous in lung sparing and reducing the chances of
radiation pneumonitis in cases where there was low or intermediate dose exposure. Specifically,
it was stated that reducing the dose to the lung V5, V20 and mean lung dose by only a few percent
could reduce the chances of radiation pneumonitis. While Chen’s data showed no statistical
significance, the current study used a larger sample size and showed statistical significance for
various measured values of lung dose. A reduction in the lung V5, V10, V20 and mean lung dose
was shown between the median values for each plan. Statistically significant reductions to the
mean lung, V10 and V5 doses were shown in the current study, which confirmed using an
additional collimator angle did reduce interleaf transmission.
The current study showed a benefit in reducing to dose to the heart. As previously stated,
for every Gy that the mean heart dose is increased, the risk for ischemic heart disease increases
by 7.4%.3 By reducing interleaf transmission with an additional collimator rotation of 90°, the
median mean heart dose was reduced by 25.3%. This reduction was statistically significant
following WSR testing and confirmed this technique could be utilized to help meet strict dose
constraints, similar to the MROQC breast studies. Finally, reductions to both the Dmax and mean
LAD doses were also shown and were due to the reduction of interleaf transmission.
The results of the current study were consistent with the findings of Chapek et al,9 which
suggested that using optimal collimator angles, meant to reduce interleaf transmission, could
reduce the dose to surrounding critical structures. In addition, the current study findings were
confirmed using a much larger sample size. While the Chapek’s study findings applied to
prostate treatments,9 the same concept can now be applied to standard breast cancer treatment.
The current study confirmed that both left and right-sided breast treatment plans can be improved
with minimal changes to the treatment planning process and workflow.
Conclusion
The reduction of interleaf transmission, by using an additional collimator rotation of 90°,
can reduce the dose to critical structures in standard whole breast irradiation. The greatest effects
were observed in the difference of the mean and Dmax heart dose; the mean, V10 and V5 for the
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lung, and mean and Dmax dose for the LAD. Each of the listed values were found to be statically
significant (P < 0.05). While most critical structures displayed a reduction in dose, not all the
dose categories were found to be statistically significant. Specifically, the difference in paired
lung V20 was not statistically significant. In addition, adequate coverage was maintained
throughout all plans and any minimal decrease in PTV coverage was determined to be clinically
insignificant.
The limitations of this study include the retrospective nature of the study and the fact that
the technique was only tested at a single institution using a single TPS and algorithm.
Retrospective studies are subject to selection bias; therefore, the results of this study may not be
generalized to a broader population of patients. Utilizing multiple institutions could provide a
larger population of patients as well as greater determined significance. This research could be
completed using different linear accelerators or a different TPS for the same anatomical site.
Further research may focus on the specific quadrants of the breast to determine if there is any
influence on dose reduction to the critical structures. Additional research may also be completed
to evaluate if rotating the collimator can reduce dose to critical structures in other anatomical
locations.
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References

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stage breast cancer treated with hypofractionated radiotherapy following breast-
conservative surgery. J Clin Oncol. 2013:73.
2. Duma MN, Münch S, Oechsner M, Combs SE. Are heart toxicities in breast cancer
patients important for radiation oncologists? A practice pattern survey in german
speaking countries. BMC Cancer. 2017;17(1):563. https://dx.doi.org/10.1186/s12885-
017-3548-2.
3. Darby SC, Ewertz M, McGale P, et al. Risk of ischemic heart disease in women after
radiotherapy for breast cancer. N Engl J Med. 2013;368(11):987-998.
https://dx.doi.org/10.1056/NEJMoa1209825.
4. Taylor CW, Kirby AM. Cardiac side-effects from breast cancer radiotherapy. Clin Oncol.
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therapy: A systematic review of heart doses published during 2003 to 2013. Int J Radiat
Oncol Biol Phys. 2015;93(4):845-853. https://dx.doi.org/10.1016/j.ijrobp.2015.07.2292.
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concept design of an elekta radiation head with integrated 160-leaf multi-leaf collimator.
Int J Radiat Oncol Biol Phys. 2009;75(3):S722-S723.
https://dx.doi.org/10.1016/j.ijrobp.2009.07.1646.
7. Vikraman S, Janardhan N, Kataria T, et al. Study of interleaf leakage and leaf
transmission in Elekta synergy S beam modulator. Int J Radiat Oncol Biol Phys.
2010;78(3):S756-S757. https://dx.doi.org/10.1016/j.ijrobp.2010.07.1751
8. Chen J, Fu G, Li M, et al. Evaluation of MLC leaf transmission on IMRT treatment plan
quality of patients with advanced lung cancer. Med Dosim. 2018;43(4):313-318.
https://dx.doi.org/10.1016/j.meddos.2017.10.008.
9. Chapek J, Tobler M, Toy BJ, Lee CM, Leavitt DD. Optimization of collimator
parameters to reduce rectal dose in intensity-modulated prostate treatment planning. Med
Dosim. 2005;30(4):205-212. https://dx.doi.org/10.1016/j.meddos.2005.06.002.
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10. Sharma S, Manigandan D, Goyal S, Sahai P. Influence of collimator rotation on dose

distribution and delivery in intensity modulated radiation therapy for parotid cancer. Int J
Cancer Ther Oncol. 2015;3(2):3212. https://dx.doi.org/10.14319/ijcto.0302.12.
11. White J, Tai A, Arthur D, et al. Breast cancer atlas for radiation therapy planning:
Consensus definitions. Radiation Therapy Oncology Group (RTOG).
https://www.rtog.org/LinkClick.aspx?fileticket=vzJFhPaBipE= Accessed June 18, 2019
12. Van Asselen B, Schwarz M, van Vliet-Vroegindeweij C, Lebesque JV, Mijnheer BJ,
Damen EMF. Intensity-modulated radiotherapy of breast cancer using direct aperture
optimization. Radiother Oncol. https://dx.doi.org/10.1016/j.radonc.2006.04.010.
13. Pierce LJ, Feng M, Griffith KA, et al. Recent time trends and predictors of heart dose
from breast radiation therapy in a large quality consortium of radiation oncology
practices. Int J Radiat Oncol Biol Phys. 2017;99(5):1154-1161.
https://dx.doi.org/10.1016/j.ijrobp.2017.07.022.
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Figures

Figure 1. Patient lying supine with upper body in alpha cradle with both arms above head.

Figure 2. A) Collimator was set at a neutral angle (12°). B) Collimator was rotated an additional
90° to 102°so that MLC leaves run parallel to chest wall to reduce interleaf transmission.
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Figure 3. A) Median mean heart and B) max heart dose with and without 90° collimator
rotation.
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Figure 4. A) Median mean LAD and B) max LAD dose with and without 90° collimator
rotation.
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Figure 5. A) Median mean lung and volume of lung receiving B) 20 Gy, C) 10 Gy, and D) 5 Gy,
with or without 90° collimator rotation.
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Figure 6. A) Dose distribution in the central axis transverse slice before a collimator rotation. B)
Dose distribution in the central axis transverse slice after an additional 90° collimator rotation.
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Table

Table 1: Comparison of the median dosimetric data of critical structures between the plans with no additional
collimator rotation (NCR) and the plans with an additional collimator rotation (CR) using the non-parametric
Wilcoxon Signed Ranks test.
NCR CR Neg. Ranks Pos. Ranks Tied Ranks Effect Size P value
Heart Mean (Gy) 0.83 0.62 64 0 1 0.86 < 0.001†
Dmax (Gy) 5.2 4.6 55 9 1 0.72 < 0.001†
LAD Mean (Gy) 2.7 2.4 34 1 0 0.81 < 0.001†
Dmax (Gy) 4.7 5 30 5 0 0.73 < 0.001†
Ipsilateral Mean (Gy) 4.4 4.2 55 8 2 0.78 < 0.001†
Lung V20 (%) 7.4 7.2 36 26 3 0.17 0.164†
V10 (%) 11.8 11.2 44 20 1 0.48 < 0.001†
V5 (%) 18 16.9 56 8 1 0.78 < 0.001†
PTV_Eval 100% 88.7 88.2 32 31 2 0.03 0.834‡
Coverage 95% 99.3 99.2 36 23 6 0.33 0.007†
90% 100 100 26 10 29 0.30 0.015†
† Based on positive ranks
‡ Based on negative ranks
Left Anterior Descending Artery (LAD), Planning Target Volume Evaluation (PTV_Eval)