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Radiologie München advances breast cancer treatments with prone deep inspiration breath hold and ExacTrac Dynamic Surface
Radiologie München, a private healthcare group, operates three radiotherapy sites across Munich, Germany with a total of five linear accelerators, one with ExacTrac Dynamic and three with ExacTrac Dynamic Surface. Treating approximately 1,500 tumor patients annually, their focus lies on improving treatment quality and the patient experience while also increasing efficiency.
Following the installation of Brainlab ExacTrac Dynamic Surface in May 2025 on an Elekta Versa HD linac, the device has been fully integrated into their routine clinical workflows. It is utilized for initial patient setup and intrafraction monitoring for all patients and indications, including deep inspiration breath hold (DIBH) treatments for breast cancer patients.
Dr. Gregor Habl, radiation oncologist at Radiologie München, shared insights gained from patients and their clinical team: “The ability to perform treatments supported by ExacTrac Dynamic Surface without permanent skin markings has contributed to improved patient comfort, while also streamlining workflows and enabling treatment durations of approximately 10 minutes per session.”
Exploring the benefits of prone DIBH
The implementation of prone positioning in combination with DIBH has recently been expanded for breast cancer treatments at Radiologie München. The technique was introduced and established in the clinic by the clinical team and their medical physicist colleague Dr. Nils Temme, who brought his clinical experience with a prone breast board from his previous institution.
Dr. Steffen Hennies, radiation oncologist at Radiologie München, explained: “This approach provides significant dosimetric advantages, particularly for left-sided breast cancer, by further reducing radiation exposure to organs at risk, including the heart and lung. While prone positioning offers substantial benefits, one challenge is that gravity can cause the heart to move closer to the anterior thoracic wall and therefore nearer to the breast target volume. DIBH provides an effective solution, as lung expansion during deep inspiration displaces the heart medially and caudally, away from the planning target volume (PTV). This treatment concept is supported by published clinical evidence and forms the basis of our current workflow.”
Dr. Temme, medical physicist at Radiologie München, added: “Our own clinical data demonstrate that compared to supine DIBH, prone DIBH has reduced the mean heart dose from 1.87 Gy to 1.64 Gy, and even more importantly, the mean dose to the ipsilateral lung has reduced from 6.06 Gy to just 1.71 Gy.”
Workflow at Radiologie München for prone DIBH treatments with ExacTrac Dynamic
For prone DIBH treatments, patients are positioned on a dedicated prone breast board designed for both left- and right-sided treatments using specialized inserts. The free-breathing CT is used for initial setup and to define the treatment baseline. Following image-guided verification of the patient position, treatment starts once the patient's breathing reaches the defined DIBH level and remains within the specified thresholds.
During imaging and treatment delivery, patients are guided into breath hold using audio instructions. Dr. Temme says: “This approach has proven highly effective, with patients consistently achieving the intended breath hold position.” Treatment delivery is automatically initiated once both the respiratory signal and the surface tracking region meet predefined tolerance thresholds. ExacTrac Dynamic Surface supports the complete workflow from the initial setup phase to monitoring.
Future Directions
Currently, Radiologie München performs prone DIBH treatments for breast-only irradiation. Looking to the future, the team aims to expand the technique to include regional lymph node irradiation.
Picture: ©Radiologie München, Team Wolfratshausen, Germany