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Stereotactic radiosurgery (SRS) for brain metastases and the implications to normal brain
tissue with flattening filter free (FFF) versus flattening filter (FF) beams: A Case Study

Authors: Melissa Wojno, Dakota Sturgess, R.T.(T), Chelsea Gehrig, R.T.(T), Nishele Lenards,
PH.D., CMD, R.T.(R)(T), FAAMD, Ashley Hunzeker, M.S., CMD, Matt Tobler, CMD, R.T.(T),
FAAMD
Medical Dosimetry Program at the University of Wisconsin - La Crosse

I. Abstract
II. Introduction
a. PI: Discuss details of radiation therapy, brain metastases, and importance of
limiting dose to surrounding organs at risk (OAR), specifically healthy brain
tissue. Discuss the constraint of volume of healthy tissue receiving 12 Gy
(Reference: C Belka, et al,1 C Groenewald, et al,2 HJ Manz, et al3)
b. PII: Introduce radiation therapy techniques that are used to limit dose to OAR
such as volumetric arc therapy (VMAT) and stereotactic radiosurgery (SRS).
(Reference: O Cohen-Inbar, et al4)
c. PIII: Discuss SRS with flattening filter (FF) and flattening filter free (FFF) beams
(Reference: M Kretschmer, et al,5 SD Sharma, et al6)
d. PIV: Summarize Introduction
i. Problem: The problem is that brain metastases patients with 5 to 9 targets
receive a higher total dose of radiation resulting in higher volume of
healthy brain tissue receiving a dose of 12 Gy.
ii. Purpose: The purpose of this study is to determine if FFF beams will
decrease the volume of healthy brain tissue receiving 12 Gy when treating
5 to 9 targets when compared to FF.
iii. Hypothesis: The research hypothesis (H1) is that using FFF beams for
SRS brain VMAT plans will reduce the volume of normal tissue receiving
12 Gy compared to FF beams. The corresponding null hypothesis (H10) is
that using FFF beams for SRS brain VMAT plans will not reduce the
volume of normal tissue receiving 12 Gy compared to FF beams.
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III. Case Description

a. Patient Selection
i. PI: Inclusion Criteria
1. Retrospective
2. 6XFFF
3. 5-9 targets
4. One isocenter
b. Target Delineation
i. PI: Targets (PTV) and OAR (Normal brain tissue)
c. Treatment Planning
i. PI: Planning details (Table 1)
1. Field arrangements and arc geometry
ii. PII: OAR constraints from QUANTEC3
d. Plan Analysis and Evaluation
i. PI: Brain analysis metrics (V12)
1. 5 patients (test cases)
2. Mean PTV volume of 3.04 cm3
3. Figures 1, 2, & 3
a. Examples of tumor location and DVH for patient B
4. Statistics: paired t-test
ii. PII: V12 results (Table 2)
1. Metrics were statistically significant.
a. P = 0.0135
iii. PIII: Summary of results
1. Metrics are significant
2. Null hypothesis H10 was rejected
IV. Conclusion
a. PI: Summarize purpose of study
i. Though statistics are significant, discuss if the change in tissue dose it
clinically relevant
ii. Review advantages of FFF compared to FF
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b. PII: Summarize results

c. PIII: Limitations/future research
i. Small sample size
ii. From same institution
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References
1. Belka C, Budach W, Kortmann RD, Bamberg M. Radiation induced CNS toxicity--
molecular and cellular mechanisms. Br J Cancer. 2001;85(9):1233-9.
http://doi.org/10.1054/bjoc.2001.2100
2. Groenewald C, Konstantinidis L, Damato B. Effects of radiotherapy on uveal melanomas
and adjacent tissues. Eye (Lond). 2013;27(2):163-171.
http://doi.org/10.1038/eye.2012.249
3. Lawrence YR, Li XA, el Naqa I, et al. Radiation dose–volume effects in the brain. Int J
Radiat Oncol Biol Phys. 2010;76(3). https://doi.org/10.1016/j.ijrobp.2009.02.091
4. Liu L, Yang Y, Guo Q, et al. Comparing hypofractionated to conventional fractionated
radiotherapy in postmastectomy breast cancer: a meta-analysis and systematic review.
Radiat Oncol. 2020;15(17). http://doi.org/10.1186/s13014-020-1463-1
5. Cohen-Inbar O, Sheehan JP. The role of stereotactic radiosurgery and whole brain
radiation therapy as primary treatment in the treatment of patients with brain
oligometastases - A systematic review. J Radiosurg SBRT. 2016;4(2):79-88.
6. Kretschmer M, Sabatino M, Blechschmidt A, Heyden S, Grunberg B, Wurschmidt F. The
impact of flattening-filter-free beam technology on 3D conformal RT. Radiat Oncol.
2013;8(133). http://doi.org/10.1186/1748-717X-8-133
7. Sharma SD. Unflattened photon beams from the standard flattening filter free
accelerators for radiotherapy: advantages, limitations and challenges. J Med Phys.
2011;36(3):123-125. http://doi.org/10.4103/0971-6203.83464
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Figures

Figure 1. Transverse, 3D, coronal, and sagittal view show the location multiple PTV in relation
to the whole brain tissue.

Figure 2. Dose volume histogram (DVH) of the PTV volumes and Brain-PTV volume of the
FFF Beam plan of Patient B.
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Figure 3. Dose volume histogram (DVH) of the PTV volumes and Brain-PTV volume of the FF
Beam plan of Patient B.
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Tables
Table 1. Example of arc geometry for the flattening filter and flattening filter free plans shows
the path of the gantry, the collimator rotation, and couch rotation used for one patient test case.
Arc Number Gantry Angles Collimator Couch Rotation
Angles
Flattening Filter 1 181.0 CW 179.0 85° 0°
Beam (FF) 2 179.0 CCW 0.0 85° 45°
3 0.0 CW 181.0 30° 315°
4 181.0 CCW 0.0 30° 270°
Flattening Filter 1 181.0 CW 179.0 85° 0°
Free Beam (FFF) 2 179.0 CCW 0.0 85° 45°
3 0.0 CW 181.0 30° 315°
4 181.0 CCW 0.0 30° 270°
*Clockwise (CW); counterclockwise (CCW)

Table 2. Dose limits serve as planning constraints for the organs at risk (OAR) in plan
evaluation.
Patient Flattening Filter Number PTV Volume Brain - PTV Brain-PTV
Beam (FF) vs. of (cm3) Volume (cm3) Volume
Flattening Filter Lesions Receiving
Free Beam (FFF) 12 Gy
(cm3)
1 FF 9 2.5 1313.3 13.95
FFF 13.79
2 FF 5 4.5 1285.7 14.08
FFF 13.57
3 FF 6 3.4 1365.1 15.19
FFF 14.93
4 FF 5 0.8 1270.1 6.01
FFF 5.87
5 FF 7 4 1076.8 14.82
FFF 14.17
Mean FF 6.4 3.04 1262.2 12.81
FFF 12.47