1

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
Respiratory motion represents geometrical uncertainty, decreasing the accuracy of
thoracic radiation therapy. To limit this motion during intensity modulated radiation therapy
(IMRT), lung cancer patients must hold their breath for multiple breath-holds as the radiation is
being delivered. This is a crucial aspect of lung irradiation, as it is necessary to limit the dose to
healthy tissue and nearby organs at risk (OAR). Lung cancer patients required to hold their
breath during IMRT must do so by completing multiple breath-holds while on the treatment
machine, thereby extending their radiation treatment time. Developments in IMRT techniques
and the higher dose rate associated with flattening filter free (FFF) beams embrace the possibility
of a viable solution. Combining IMRT with FFF beams improved delivery of higher radiation
doses in a shorter amount of time, while maintaining treatment goals and improving patient
outcomes.1
To highlight the impact of breath-hold during radiation treatment, the American
Association of Physicists in Medicine (AAPM) Task Group 76 released a report in 2006 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. Respiratory
motion management is recommended if the following criteria are observed: tumor motion > 5.0
mm, a method of respiratory motion management is available, and the patient can tolerate the
procedure.2 In 2020, the AAPM formed Task Group 324, conducting a survey of current AAPM
members to update Task Group 76 given the growth and technological changes in respiratory
motion management since 2006. Task Group 324 summarized the current state-of-the-art
practice techniques for motion management, highlighting the importance of individualized
patient motion management plans based on patient-specific characteristics, such as tumor
location, patient anatomy, and treatment delivery technique. The findings and recommendations
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of the AAPM Task Group 324 report provide a framework for improving motion management in
radiation therapy and patient outcomes overall.2
Building on AAPM Task Groups 76 and 324, the geometric uncertainties such as organ
motion, setup errors, tumor delineation and/or respiratory motion can hinder the accuracy of
radiation treatments. Limiting respiratory motion in lung radiation treatment is a crucial factor
that enables the reduction of treatment volumes and minimizes the exposure of healthy tissue.3
Advancements in technology have allowed for the development of multiple breath-hold
techniques that can be utilized for respiratory motion management, including Active Breathing
Coordinator (ABC) and VisionRT. These techniques decrease the risk of respiratory motion
uncertainties and related treatment complications. Some patients, however, experience difficulty
during the multiple breath-holds required during treatment even when utilizing motion
management. By removing the flattening filter (FF) from the traditional IMRT technique, an
irregular dose profile with an enhanced central peak and sharp dose fall-off is produced, which
results in a higher dose rate allowing for a reduction in treatment time.4 This technique has also
demonstrated a reduction in scatter and radiation leakage, demonstrating its use as a multi-
faceted benefit in IMRT breath-hold treatment.5
Previous researchers have established the efficacy of flattening filter-free intensity
modulated radiation therapy (FFF-IMRT) in achieving clinically significant reductions in
treatment time when compared to IMRT with a flattening filter (FF-IMRT). Zeghari et al6
determined that FFF-IMRT reduced treatment times by an average of 2.5 minutes per fraction
compared to FF-IMRT. This data indicates a consistent reduction in beam on-time by utilizing
FFF beams for lung lesions. In addition to a decrease in physical beam-on time, the subsequent
reduction in overall individual treatment time has also been noted. The primary advantage of
FFF beams is that the shortened physical beam on-time also decreases the overall individual
treatment time, while maintaining similar MU.7
The increased dose rate, reduced scatter, and decreased treatment time associated with the
use of FFF-IMRT are cornerstones in optimal radiation treatment.8 The reduction in treatment
time is particularly beneficial in the case of lung cancer patients required to hold their breath
during intensity modulated radiation.9. Researchers evaluated and compared three metrics for
this case study: treatment delivery time, dose to OAR, and volume coverage of prescribed dose.
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Researchers assesses the feasibility of FFF-IMRT leading to a reduction in treatment time of >
40%, while maintaining OAR dose constraints and prescribed target metrics (H1A).
Case Description
Patient Selection & Setup
Patients in this retrospective study were diagnosed with left-sided lung cancer. The
inclusion criteria consisted of patients receiving IMRT at breath-hold with two arcs using 6FF.
Patients were simulated using a Philips CT scanner in the headfirst supine position on a wing
board, at breath-hold for their CT planning scans. A custom immobilization device was created
for each patient with their arms placed above their head to allow for subsequent position
replication. Radiopaque markers were placed on the patient's external skin and/or immobilization
device for patient setup and triangulation, followed by 3 separate CT scans performed by the
radiation therapists. The respiratory motion management system used was ABC. The patients
had a soft clip placed over their nose with a tube to breathe through inserted into their mouth, to
ensure their breathing could be monitored by the system. During simulation, the radiation
therapists instructed the patient on proper breathing methods, determining an appropriate
threshold and breath-hold time length for the patient.
Target Delineation
Treatment planning and target delineation was performed in Pinnacle 16.2 treatment
planning software (TPS). The radiation oncologist determined which breath-hold scan should be
used for treatment planning, and the scans were imported into the TPS. The medical dosimetrist
contoured the OAR to include any organs proximate to the dose distribution. The OAR indicated
for lung IMRT consisted of the bilateral lungs, heart, and spinal canal. The OAR contours were
reviewed by the radiation oncologist, who proceeded to contour the planning target volume
(PTV). To maintain target alignment during treatment, the radiation therapists followed the
prescription for alignment and rescan tolerances. A cone-beam CT (CBCT) was completed prior
to start of treatment to account for any anatomical shifts that may have occurred or due to tumor
regression from radiation treatment delivery.10 Patient set-up was done according to the
specifications given by the simulation instructions.
Treatment Planning
During treatment planning, the medical dosimetrist established an isocenter based on the
radiopaque markers used during the simulation scan. This location was given to the radiation
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therapists, as isocenter, to ensure patient set-up was consistent during all subsequent radiation
treatments. After this location was selected on the TPS, the medical dosimetrist began treatment
planning using the PTV and/or fields set by the radiation oncologist. Each beam arrangement
consisted of 2 full VMAT arcs with beam energies of either 6FF or 6FFF. The target metric
objectives that were used included prescribed dose constraints, at 100% of the volume receiving
the prescription dose. The OAR dose constraints used by the medical dosimetrist were in
measurements of volume (V), and dose maximum (Dmax) in centi-gray (cGy). The OAR dose
constraints included V30 for the heart, V20 for the contralateral lung, and Dmax (cGy) at a point
0.03cc for the spinal canal. Individual patient results were measured using these OAR
constraints; with an evaluation of the doses delivered to the PTV and OAR, along with overall
treatment time.
Plan Analysis & Evaluation
All plans met OAR constraints, as defined by QUANTEC and physician references. A
dose volume histogram (DVH) was used to evaluate constraints of each plan regarding target and
OAR dose, and presented a comparison between the 6FF and 6FFF plans for each patient. The
mean tumor dose (MTD) was evaluated using centi-gray (cGy), with all patients' plans
prescribed between 4500-6500 cGy; and the monitor units (MU) of each individual arc were
calculated to determine the actual beam on time. Both the contralateral lung dose V20 and heart
dose V30 were volumetrically measured due to patient specific anatomy, such as individual lung
volumes and target location relative to the heart, and the Dmax within the spinal canal was
assessed using cGy at a volume of 0.03cc.
All 6FF plans utilized 600 MU/min while 6FFF plans utilized 2000 MU/min. Assessing
the MTD demonstrated minor change for all 5 patient cases between the 6FF and 6FFF plans.
Patient cases 1, 4, and 5 demonstrated higher MTD in the 6FFF plans, while cases 2 and 3
demonstrated lower. However, regardless of the minor change in MTD, all targets still received
full prescription. The MU results also signified similar minor change; where patient cases 1, 4,
and 5 demonstrated higher MU in 6FFF plans, while cases 2 and 3 demonstrated lower. The
average beam-on time was reduced 70%, with a dose rate 3 times higher, and was calculated
with the arcs’ MU divided over the dose rate.
The contralateral lung V20 results showed minimal to no change in all 5 patient cases for
both 6FF and 6FFF techniques; with the V20 value averaging 3% for patient cases 3 and 4, and
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0-1% for cases 1,2 and 5 with the V20 < 7% constraint. The heart V30 results also demonstrated
minimal to no change for both 6FF and 6FFF techniques in all patient cases. Assessing the V30
< 20% constraint, proximity of target to the heart played an influential role in dose. Patient cases
1, 2 and 3 averaged 10-18% due to adjacency of target to heart, but only 2% for case 4 and 5
where the target and heart exhibited greater separation. All patient cases met lung V20 <7% and
heart V30 < 20% constraints. In summary, these results support the hypothesis (H1A) that states
utilizing 6FFF technique will reduce treatment time ≥ 40% compared to an FF technique, while
maintaining constraints of OAR and mean tumor dose.
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