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Radiation Treatment Time Efficiency And Dose Comparison For Intensity Modulated
Radiation Lung Treatment at Breath-Hold Using Flattening Filter and Flattening Filter-
Free Techniques: A Case Study

Authors: Amanda Tabar R.T.(R)(CT), Hieu Tran R.T.(T), Katelyn Fischer R.T.(T), Nishele
Lenards, Ph.D., CMD, R.T.(R)(T), FAAMD, Ashley Hunzeker, M.S., CMD, Matt Tobler, CMD

Medical Dosimetry Program at the University of Wisconsin - La Crosse

Introduction

The goal of radiation therapy is to deliver an optimal radiation treatment that eradicates
the tumor while sparing normal tissues. Developments in intensity modulated radiation therapy
(IMRT) have allowed for additional normal tissue sparing with improved delivery of higher
radiation doses for more accurate radiation therapy treatments. The accuracy of radiation
treatments can be limited by geometric uncertainties such as organ motion, setup errors,
respiratory motion, and/or tumor delineation.1 Specific to lung radiotherapy, radiation treatment
accuracy is significantly affected by respiratory motion within the lung. Limiting respiratory
motion within the lung allows for reduced treatment volumes along with a reduction in irradiated
healthy tissue and toxicities.1 There are multiple breath-hold techniques that can be utilized for
respiratory motion management. These innovative technologies, such as Active Breathing
Controller and VisionRT, allow for lung, breast, and abdominal treatments to be done at breath-
hold; thereby eliminating the risk of respiratory motion complications. Advancements in
treatment techniques have led to increased use of flattening filter-free (FFF) beams, as they offer
many advantages over traditional flattened beams. By removing the flattening filter (FF), an
irregular dose profile with an enhanced central peak and sharp dose fall- off is produced.2 FFF
beams allow for a reduced treatment delivery time due to their higher dose rate while also
reducing scatter and radiation leakage.3 This notable decrease in radiation treatment time is one
of the appealing benefits of using the FFF technique for IMRT lung patients holding their breath
for treatment.
Multiple studies have shown that flattening filter-free intensity-modulated radiation
therapy (FFF-IMRT) can lead to clinically significant reductions in treatment time compared to
IMRT with a flattening filter.4 Zhang et al5 determined that FFF-IMRT reduced treatment times
by an average of 2.5 minutes per fraction compared to IMRT with a flattening filter. In a separate
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article written by Barbiero et al6, researchers noted an even greater reduction factor; at 2.31
minutes per fraction when switching from FF to FFF. The conclusion of this study was that FFF,
in comparison to FF, provides a significant reduction in treatment time while still providing
equally dosimetric results. This reduction in treatment time can be particularly beneficial for lung
cancer patients holding their breath for radiation treatment, who may already be experiencing
fatigue and other side effects from chemotherapy or surgery. Another study reported that the
average beam on-time for FFF beams was 6.5 minutes, which was much shorter than for FF
beams at 15.1 minutes. The researcher's data expressed an overall reduction in beam on-time by
about 57.0% using FFF beams for lung lesions.7 This increased efficiency can benefit both
patients and healthcare providers by reducing the overall treatment time and increasing the
number of patients that can be treated in the clinic daily. Wu et al8 discussed another primary
advantage of FFF beams is that they have similar MUs; meanwhile, they have a shortened beam
on-time compared with FF beams. Their results showed that the FFF beams obtained a 23.8%
reduction in beam on-time, an 18.8% reduction in radiation treatment time and a 1.0% reduction
in MU for volumetric arc therapy (VMAT). These studies demonstrate that there is a beneficial
decrease in treatment time using FFF beams, although the exact decrease in treatment time was
clinic and case dependent.
In 2006, the American Association of Physicists in Medicine (AAPM) Task Group 76
released a report on the management of respiratory motion in thoracic, abdominal, and pelvic
tumors. This AAPM Task Group recommended measuring tumor motion for each patient when
possible. The AAPM recommended utilizing respiratory motion management if the following
criteria are observed: if tumor motion is greater than 5 mm, a method of respiratory motion
management is available, and the patient can tolerate the procedure.9 In 2020, the AAPM formed
Task Group 324 to update Task Group 76, given the growth and technological changes in
respiratory motion management since 2006 by conducting a survey of current AAPM members.
The report from Task Group 324 summarized the current state-of-the-art practice techniques for
motion management, including imaging modalities, motion tracking devices, and treatment
delivery systems.9 It highlighted the importance of individualized patient motion management
plans based on patient-specific characteristics, such as tumor location, patient anatomy, and
treatment delivery technique. Furthermore, the report emphasized the need for collaboration
between radiation oncologists, medical physicists, and radiation therapists to develop and
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implement effective motion management strategies. The article concluded that the findings and
recommendations of the AAPM Task Group 324 report provide a framework for improving
motion management in radiation therapy and patient outcomes overall.9
Expecting to shorten treatment time with similar or enhanced dosimetric outcomes, FFF
beams have promising features that can improve patient outcomes.10 By increasing the dose rate,
radiation treatment time is decreased, leading to improved patient satisfaction due to less
physical time required on the treatment table.11 Lung cancer patients required to hold their breath
for the duration of IMRT cases experience difficulty completing multiple breath-holds while on
the treatment machine, thereby extending their radiation treatment time. The present study
sought to evaluate the impact of the flattening filter-free technique on shortening treatment
delivery time for patients holding their breath while receiving intensity modulated radiation
therapy treatment. The objective of this case study is to conduct a comparative analysis between
the utilization of a flattening filter technique and a flattening filter-free technique, to assess
whether using the flattening filter-free technique reduces treatment time by 40%, while
maintaining organ at risk (OAR) dose constraints and mean tumor dose. Researchers evaluated
and compared three metrics including treatment delivery time, dose to organs at risk (heart,
spinal canal, & right lung), and mean dose to tumor. They tested the hypothesis that using the
FFF technique will reduce treatment time ≥ 40% compared to an FF technique, while
maintaining OAR dose constraints and mean tumor dose (H1A). A low toxicity rate combined
with a shortened treatment time, make utilization of the FFF technique optimal in support of
patient outcomes.12
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References

1. Botticella A, Levy A, Auzac G, Chabert I, Berthold C, Le Pechoux C. Tumour motion

management in lung cancer: a narrative review. Transl Lung Cancer Res.
2021;10(4):2011-2017. doi:10.21037/tlcr-20-856
2. Ghemiş DM, Marcu LG. Progress and prospects of flattening filter free beam technology
in radiosurgery and stereotactic body radiotherapy. Crit Rev Oncol Hematol.
2021;163:103396. doi:10.1016/j.critrevonc.2021.103396
3. Vassiliev ON, Kry SF, Wang HC, Peterson CB, Chang JY, Mohan R. Radiotherapy of
lung cancers: FFF beams improve dose coverage at tumor periphery compromised by
electronic disequilibrium. Phys Med Biol. 2018;63(19):195007.
doi:10.1088/1361-6560/aadf7d
4. Moustamia A, Muraro S, Julian D. 25 Dosimetric impacts of FFF large-field beams for
lung cancer VMAT treatment. Physica Medica. 2018;56:51
https://doi.org/10.1016/j.ejmp.2018.09.107
5. Zhang DG, Feygelman V, Moros EG, et al. Superficial and peripheral dose in
compensator-based FFF beam IMRT. J Appl Clin Med Phys. 2017;18(1):151-156.
doi:10.1002/acm2.12018
6. Barbiero S, Rink A, Matteucci F, et al. Single-fraction flattening filter-free volumetric
modulated arc therapy for lung cancer: Dosimetric results and comparison with flattened
beams technique. Med Dosim. 2016;41(4):334-338. doi:10.1016/j.meddos.2016.09.002
7. Pokhrel D, Halfman M, Sanford L. FFF-VMAT for SBRT of lung lesions: Improves dose
coverage at tumor-lung interface compared to flattened beams. J Appl Clin Med Phys.
2020;21(1):26-35. doi:10.1002/acm2.12764
8. Wu J, Song H, Li J, Tang B, Wu F. Evaluation of flattening-filter-free and flattening filter
dosimetric and radiobiological criteria for lung SBRT: A volume-based analysis. Front
Oncol. 2023;13:1108142. doi:10.3389/fonc.2023.1108142
9. Ball HJ, Santanam L, Senan S, Tanyi JA, van Herk M, Keall PJ. Results from the AAPM
Task Group 324 respiratory motion management in radiation oncology survey. J Appl
Clin Med Phys. 2022;23(11):e13810. doi:10.1002/acm2.13810
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10. Arslan A, Sengul B. Comparison of radiotherapy techniques with flattening filter and
flattening filter-free in lung radiotherapy according to the treatment volume size. Sci Rep.
2020;10(1):8983. doi:10.1038/s41598-020-66079-6
11. Ma C, Chen M, Long T, et al. Flattening filter free in intensity-modulated radiotherapy
(IMRT) - Theoretical modeling with delivery efficiency analysis. Med Phys.
2019;46(1):34-44. doi:10.1002/mp.13267
12. Annede P, Darreon J, Benkemouche A, et al. Flattening filter free vs. flattened beams for
lung stereotactic body radiation therapy. Anticancer Res. 2017;37(9):5133-5139.
doi:10.21873/anticanres.11933