Pneumothorax Associated With Deep Inspiration Breath Holding During Radiation Therapy for Breast Cancer

A 49-year-old woman was treated for invasive ductal carcinoma of the left breast American Joint Committee on Cancer stage IIB (pT1b pN1a cM0) in 2015. She had a history of spontaneous pneumothorax, occurring twice in the right lung, first occurring in July of 2004, then again in October of 2014. This was associated with a history of congenital bullae (Fig. 1) and after prolonged coughing after upper respiratory illnesses. Both previous pneumothoraces were resolved with basilar chest tubes. The patient's breast cancer was treated with lumpectomy and postoperative radiation. She received whole breast radiation that encompassed the level I to II axilla 5000 cGy in 25 fractions and a sequential lumpectomy bed boost of 1000 cGy in 5 fractions. The radiation technique used deep inspiration breath hold radiation (DIBH) using the spirometry-based breath-hold system SDX (DYN'R Medical Systems). After the patient's 23rd radiation treatment, the patient noted tightness and a crackling sound in her chest. She was without shortness of breath or hypoxia. A chest x-ray revealed a right pneumothorax covering 40% to 50% of the lung space (Fig. 2) with a new small right pleural effusion. She was admitted and within a few hours of the diagnosis treated by placement of a basilar chest tube into the right lung base. Within 3 days of the initial chest tube placement, the pneumothorax was resolved. There was no treatment break needed. Her radiation was replanned before the next day on the free-breathing scan obtained at her original computed tomography (CT) simulation, and the next day she had a repeat verification simulation (setup) on the machine. Her remaining 7 radiation treatments were delivered with free breathing. Two years later she was treated by pleurodesis and had no additional episodes. Figure 2Pneumothorax after a radiation treatment with deep inspiration breath holding for left-sided breast cancer. View Large Image Figure Viewer Download Hi-res image