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

I. Abstract
II. Introduction
A. PI: Details of intensity modulated radiation for lung cancer treatment including
standard of care, respiratory motion management, radiation therapy dose, mean
treatment time (Reference: Arslan et al1).
B. PII: Introduction of American Association of Physicists in Medicine (AAPM)
Task Group 76 and current report recommendations for the management of
respiratory motion, including breath hold (Reference: Ball et al,2 Botticella et al,3
Ghemis et al,4 Vassilev et al5).
C. PIII: Introduction to flattening filter free (FFF) and flattening filter (FF) technique
(Reference: Zhang et al6). Advancement of treatment techniques and increased
use of FFF beams for lung radiation treatment (Reference: Wu et al,7)
D. PIV: Summarize introduction and introduce the comparison of flattening filter
versus flattening filter free techniques as evaluation tool for intensity modulated
radiation treatment (IMRT). Discuss evaluation of treatment time, target metrics
and OAR dose. (Reference: Ma et al8, Moustamia et al,9 Sajja et al10)
1. Problem: Lung cancer patients required to hold their breath
during intensity modulated radiation therapy (IMRT) must do so by
completing multiple breath-holds while on the treatment machine, thereby
extending their radiation treatment time.
2. Purpose: The objective of this case study is to assess the
feasibility of FFF-IMRT, in comparison to FF-IMRT, leading to a
reduction in treatment time of > 40%, while maintaining OAR dose
constraints and prescribed target metrics (H1A).  
 2

III. Case Description

A. Patient Selection
1. PI: Inclusion Criteria
a. Retrospective
b. Lung cancer treated at breath-hold with 2 VMAT arcs
a. Left-sided to maintain consistent OAR evaluation
c. External beam treating with 6 MV
2. PII: Simulation procedures
a. Respiratory gating
B. Target Delineation
1. PI: Target (PTV) and OAR (heart, spinal canal, & right lung)
2. PII: CBCT alignment
a. ABC tolerances
C. Treatment Planning
1. PI: Planning Details (Table 1)
a. 6 MV vs. 6FFF
b. Field arrangement
c. Collapsed cone algorithm
d. Pinnacle and Raystation treatment planning systems
2. PII: Target Metrics
a. Prescribed target constraints
b. Treatment time including CBCT
3. PIII: OAR Constraints (Table 2)
a. Heart V30
b. Spinal canal Dmax(Gy)
c. Contralateral lung V20
4. PIV: Patient(s) Results (Table 3)
a. Target coverage
b. OAR constraints
c. Treatment time
D. Plan Evaluation
 3

1. P1: Mean treatment time

2. P2: Dose Constraints (Figures 1 & 2)
a. OAR metrics
b. Target metrics
IV. Results
A. PI: Treatment time utilizing 6 FF-IMRT
1. Treatment time
2. OAR dose
a. Heart V30
b. Spinal canal Dmax(Gy)
c. Contralateral lung V20
3. Target constraints
a. 100% isodose coverage of 95% target volume - PTV
B. PII: Treatment time utilizing 6 FFF-IMRT
1. Treatment time
2. OAR dose
a. Heart V30
b. Spinal canal Dmax(Gy)
c. Contralateral lung V20
3. Target constraints
a. 100% isodose coverage of 95% target volume
C. PIII: Study evaluation
1. Mean treatment times
2. Mean OAR dose
a. Heart V30
b. Spinal canal Dmax(Gy)
c. Contralateral lung V20
3. Mean target constraints
a. 100% isodose coverage of 95% target volume
 4

References 
1. 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. https://doi.org/10.1038/s41598-020-66079-6 
2. 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. https://doi.org/10.1002/acm2.13810  
3. 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. https://doi.org/10.21037/tlcr-20-856  
4. 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. https://doi.org/10.1016/j.critrevonc.2021.103396  
5. 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.
https://doi.org/10.1088/1361-6560/aadf7d  
6. Zeghari A, Saaidi RC, et al. Monte Carlo study of a free flattening filter to increase dose
on 12 MV photon beam. J Radiat Res. 2020;18(2):1-2907.
https://doi.org/10.18869/acadpub.ijrr.18.2.307 
7. 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. https://doi.org/10.3389/fonc.2023.1108142  
8. 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. https://doi.org/10.1002/mp.13267 
9. 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

10. Sajja S, Lee Y, Eriksson M, et al. Technical principles of dual-energy cone beam
computed tomography and clinical applications for radiation therapy. Adv Radiat Oncol.
2020;5(1):1-16. https://doi.org/10.1016/j.adro.2019.07.013