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 undergoing intensity modulated
radiation therapy (IMRT) are asked to perform multiple breath-holding
sequences while on the treatment machine, thereby extending radiation
treatment duration.
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).
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
 1. P1: Mean treatment time
2. P2: Dose Constraints (Figures 1 & 2)
a. OAR metrics
b. Target metrics
IV. Analysis & Study Evaluation
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
V. Discussion
A. PI: Summarize results
 1. Problem and purpose statements
2. Summary of evaluation
a. Mean treatment times
b. Mean OAR dose
c. Mean target constraints
B. PII: Discussion of how results can benefit future practice changes
1. Discussion and reflection of case study
a. Details of intensity modulated radiation (Reference: Arslan et al1)
b. AAMP recommendations on respiratory management (Reference:
Ball et al,2 Botticella et al,3 Ghemis et al,4 Vassilev et al5)
c. Flattening filter free (FFF) and flattening filter (FF) technique
(Reference: Zeghari et al,6 Wu et al7)
d. Evaluation of treatment time, target metrics and OAR dose
(Reference: Ma et al8, Moustamia et al,9 Sajja et al10)
VI. Conclusion

A. PI: Success of FFF-IMRT

B. PII: Limitations and future research

1. Limitations: data volume, time constraints, construct validity

2. Future research studies
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