1

Effects of target volume coverage in superficial medial and lateral breast tissue using
flattening filter-free beams.

Authors: Simran Rai R.T.(T), Sunhee Lee, CMD, R.T.(T), Janice Chuang, 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

Abstract
Three-dimensional conformal radiation therapy (3D-CRT) plays a major role in breast-
conserving therapy. Achieving target coverage is difficult when tangential separation of the
breast requires use of mixed energy beams. The problem is that the higher energies from mixed
energy treatment can lead to a loss of peripheral dose in the outer region of breast tissue which is
of concern for patients with a medial or lateral lumpectomy cavity when receiving whole breast
radiation. Using flattening filter free (FFF) beams may benefit superficial target coverage due to
the increased surface dose. The purpose of this study was to determine if 10 MV FFF beams
could increase peripheral dose coverage to the outer region of breast tissue and the lumpectomy
cavity compared to mixed energy treatment techniques for patients (n=7) receiving whole breast
irradiation. Researchers hypothesized that 10 MV FFF treatments for breast patients would
increase the volume of the whole breast receiving 95% of the prescription dose (V95%) and
minimum cavity dose by 5% compared to mixed energy treatment techniques. Overall, the
results of the research displayed that 10 MV FFF treatments failed to provide statistically
significant coverage to breast tissue or increase minimum dose to the lumpectomy cavity.
Key Words: Flattening filter free (FFF), Breast cancer, Superficial, Mixed energy
Introduction
The adjuvant use of radiotherapy in breast-conserving therapy has resulted in excellent
long term local control for early-stage breast cancer.1 This approach has led to greater cosmetic
outcomes with similar long-term survival results compared to mastectomy. Following
lumpectomy, the whole breast is typically treated with 3D conformal radiation therapy (3D-
CRT) consisting of lateral and medial tangent beams. This is often followed by a boost to the
surgical cavity. The goal of this treatment is to deliver a homogenous dose to the breast and
surgical cavity while decreasing the dose to organs at risk (OAR).
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The goal of homogenous dose coverage to the planning target is crucial but can be
difficult at times. In general, a desirable treatment plan consists of a uniform dose distribution to
breast tissue without excessive hot spots. Vargas et al2 demonstrated that excessive areas of high
dose have been linked to poorer cosmetic outcomes. This objective becomes increasingly
difficult to balance with target coverage as patient tangential separation increases. Gustafson et
al3 demonstrated that the increased monitor units needed to deliver dose to the entire breast when
tangential separation is > 21.0 cm creates higher dose areas that in many cases cannot be
eliminated with lower energies. Conversely, Lief et al4 observed when higher energies such as 10
MV are used in these cases, a loss of dose in the peripheral region of the breast is often reported
due to the skin-sparing effect that occurs in higher energy photon beams. The availability of
energies that can provide adequate target coverage along with a low area of hot spots is one such
limitation of 3D-CRT breast planning.
Flattening Filter Free (FFF) beams have been shown to display favorable beam
characteristics that would suggest a greater likelihood of target coverage closer to the surface of
the patient. Increased surface coverage is more likely because 6 MV and 10 MV FFF beams have
a softer energy spectrum than their flattened counterpart.5 Additionally, for 10 MV FFF beams
the depth of electron equilibrium is shallower than a 10 MV flattened beam in field sizes larger
than 10x10 cm. Flattening filter free beams have also been shown to decrease treatment times
adding to its benefits.6 It can be reasoned that a FFF beam, when modulated correctly, can
provide adequate dose distribution within the breast while maintaining a therapeutic dose closer
to the skin surface.
Despite some clinical practices, adequate dose coverage near the surface is still favorable.
Li et al7 demonstrated that although the peripheral 3.0 to 5.0 mm of the breast is often omitted
when target coverage is evaluated in a plan, many radiation oncologists include it in their target
volume. Furthermore, the area near the surface of the breast becomes of particular importance in
instances where the surgical cavity is near the medial or lateral surface since the cavity is the
most common area of local recurrence as exhibited by Cossetti et al.8 The minimum dose
observed in superficial cavities can be diminished when higher energies are used. A robust
method of planning that maintains superficial target volume coverage should be addressed.
An investigation into the alternative options to mixed energy planning in whole breast
irradiation is needed. There is limited research on the clinical implications of using FFF beams to
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increase the relative dose near the surface. Whole breast tangential setups in patients with a
separation > 21.0 cm typically requires mixed energy beams for adequate coverage of breast
tissue. The problem is that the higher energies from mixed energy treatments can lead to a loss of
peripheral dose in the outer region of breast tissue which is of concern for patients with a medial
or lateral lumpectomy cavity when receiving whole breast radiation. The ability of FFF beams to
provide increased superficial dose may be able to address this issue. The purpose of this study
was to determine if 10 MV FFF beams could increase peripheral dose coverage in the outer
region of breast tissue and lumpectomy cavity compared to mixed energy treatment techniques
for patients receiving whole breast irradiation. Researchers tested the hypotheses that 10 MV
FFF treatments for breast patients would increase volume of the whole breast receiving 95% of
the prescription dose (H1A) and minimum cavity dose by 5% (H2A) compared to mixed energy
treatment techniques.
Case Description
Patient Selection & Setup:
In this retrospective study, patients that received whole breast radiotherapy in the supine
position without supraclavicular nodal involvement were selected. A prescription of 5000cGy in
25 fractions was input for each patient. The criteria included a tangential separation > 21.0 cm
and a surgical cavity that was within 1.0 cm from the surface. Tangential separation was defined
as the greatest distance for the deepest point of entry to travel outside the body on the medial and
lateral beams. For the 7 patient cases, the mean tangential separation was 23.5 cm with a range of
21.0-26.1 cm.
Patients were simulated using a Philips Brilliance Big Bore CT scanner in the headfirst
supine position. A breast board was used for immobilization with the patient’s ipsilateral arm
above their heads. To facilitate patient comfort each patient was given a knee roll and headrest.
For setup and localization, each patient was marked in 3 locations; 1 mark on each side and 1
anteriorly. Radiopaque markers were utilized during the scan to visualize a point of reference.
The boundaries of the breast tissue were delineated prior to the CT scan with radiopaque wires
by the radiation oncologist. Patients that received radiation to the left breast received 2 CT scans;
1 free breathing and 1 with a deep inspiration breath hold. All scans were obtained with a 0.2 cm
slice thickness.
Target Delineation
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Following simulation, target delineation and treatment planning were performed using
Eclipse version 15.6. treatment planning software. The calculation algorithm was
AcurosXB_15606 with a dose grid size of 0.2 cm. The surgical cavity and breast tissue were
delineated by the physician. To yield a breast planning target volume (PTV), the breast structure
was cropped 5.0 mm away from the skin surface (Figures 1, 2). The cavity volume was
unmodified. All OAR were contoured by the medical dosimetrist which included the heart,
bilateral lungs, and in the case of left breast patients, the left anterior descending artery.
Treatment Planning
Medial and lateral tangent beam were utilized in each plan. The field size, collimator
angles, and gantry angles were set by the physician so that the fields would cover the entirety of
the ipsilateral breast tissue. The physician utilized Radiation Therapy Oncology Group Protocol
(RTOG) 0413 guidance when determining the field size. To facilitate the planning process,
EZFluence software was used in the planning of all cases. Once the plans were exported to the
program, a coverage goal of volume of breast PTV receiving 95% of prescription dose to be >
95% (V95% > 95%) was put into the system for all plans. Each plan deployed the use of electronic
compensators (ECs), and every patient in the study received 2 treatment plans that had the same
field size, collimator rotation and treatment angles. One plan consisted of a 10 FFF beam energy,
and the other included a mixture of 6 MV and 10 MV treatment beams. For the mixed energy
plan, the 6 MV beam was used entirely on the tangent side nearest to the surgical cavity and the
10 MV was deployed on the opposite tangent field.
Plan Analysis and Evaluation
All plans met the OAR constraints defined by the physician (Table 1). A dose volume
histogram (DVH) was used for the evaluation of each plan to measure V95% of breast tissue and
minimum cavity dose (Figure 3). The original breast tissue delineated by the physician was used
for plan analysis since the breast PTV was used for normalization and treatment planning. The
V95% of breast tissue utilized relative volumes, and the minimum cavity dose was measured as a
percentage of the prescription. A two tailed t-test was conducted to compare the difference
between the FFF and mixed energy treatments for the V95% of breast tissue and minimum cavity
dose. The level of significance used was P < 0.05 to determine if both null hypotheses could be
rejected. A 95% confidence interval was also deployed to calculate the expected difference in
treatment outcomes for both metrics as well.
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Results
The mixed energy treatment plans provided a greater V95% for breast tissue in all 7 cases
(Table 2). With a P value < 0.001 the mixed energy plans displayed significantly greater
coverage of breast regarding 95% of the prescription dose. The 95% confidence interval was
between 1.66% and 4.09% for the mean difference in coverage between mixed energy and FFF
treatments when measuring the V95% of breast tissue. With the results of the statistical analysis,
the null hypothesis (H10) failed to be rejected.
The minimum cavity dose was greater in 3 of 7 plans for the FFF treatments compared to
mixed energy (Table 2). Patient 6 exhibited the greatest difference in favor of FFF with a
minimum cavity dose of 97.26% for FFF compared to 94.75% for mixed energy. Patient 2
showed the greatest difference in favor of mixed energy with a minimum cavity dose of 90.65%
compared to 95.44% for mixed energy. The other 5 cases had a difference of  2.0%. The P-
value of the minimum cavity dose was 0.207. The minimum cavity dose -between FFF and
mixed energy was comparable with a 95% confidence interval between -2.8 and 1.32% for the
mean difference between FFF and mixed energy. The statistical analysis resulted in a failure to
reject the null hypothesis (H20).
Ten MV FFF treatment plans did not demonstrate significantly greater V95% for breast
tissue or minimum cavity dose when compared to mixed energy plans. The results did not meet
the expectations from data published by Kragl et al,5 that demonstrated an increase in surface
dose for FFF beams compared to their flattened counterparts. However, Kragle et al5 only
analyzed beam data and did not explore the implications of FFF beams on patients directly.
Although 10 MV FFF beams may be able to provide greater dose near the surface compared to
10 MV flattened beams, the same may not be true when comparing 10 MV FFF to mixed energy
treatments that include both 6 and 10 MV flattened beams.
Conclusion
An examination of the benefits of FFF beams for breast patients with medial and lateral
superficial surgical cavities was needed to determine if it could yield greater overall coverage.
The problem is that the higher energies from mixed energy treatments can lead to a loss of
peripheral dose in the outer region of breast tissue which is of concern for patients with a medial
or lateral lumpectomy cavity when receiving whole breast radiation. The purpose of this study
was to determine if 10 MV FFF beams could increase peripheral dose coverage in the outer
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region of breast tissue and lumpectomy cavity compared to mixed energy treatment techniques
for patients receiving whole breast irradiation. Overall, the results of the research displayed that
10 MV FFF treatments failed to provide statistically significant coverage to breast tissue or
increase minimum dose to the lumpectomy cavity.
Suggestions for future research include a larger number of patients across multiple
clinics. Additionally, the use of FFF beams in breast patient with smaller tangential separation or
in the prone position could be explored. These smaller separations could lead researchers to
investigate the difference between 6 MV and 6 MV FFF beams when evaluating patients with
medial or lateral surgical cavities for peripheral dose coverage
Acknowledgement
The authors would like to thank Sherwin Toribio at the Statistical Consulting Center at UW-La
Crosse for his assistance with statistical data for this research; however, any errors of fact or
interpretation remain the sole responsibility of the authors.
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References
1. Wrubel E, Natwick R, Wright P.G. Breast conserving therapy is associated with improved
survival compared with mastectomy for early-stage breast cancer: A propensity score
matched comparison using the national cancer database. J Ann Surg Oncol. 2020;28(2): 914–
919. https://doi.org/10.1245/s10434-020-08829-4
2. Vargas L, Solé S, Solé CV. Cosmesis after early-stage breast cancer treatment with surgery
and radiation therapy: experience of patients treated in a Chilean radiotherapy
center. Ecancermedicalscience. 2018;12(1):819-826.
https://doi.org/10.3332/ecancer.2018.819
3. Gustafson NR, Burrier T, Butler B, Hunzeker A, Lenards N, Culp L. Correlation of hot spot to breast
separation in patients treated with postlumpectomy tangent 3D-CRT using field-in-field technique
and mixed photon energies. Med Dosim. 2020;45(2):134-139.
https://doi.org/10.1016/j.meddos.2019.08.00488
4. Lief EP, Hunt MA, Hong LX, Amols HI. Radiation therapy of large intact breasts using a
beam spoiler or photons with mixed energies. Med Dosim. 2007;32(4):246- 253.
https://doi.org/253.10.1016/j.meddos.2007.02.002888888888888888888888888888888
5. Kragl G, Wetterstedt S, Knäusl B, et al. Dosimetric characteristics of 6 and 10MV
unflattened photon beams. Radiat Oncol J. 2009;93(1):141-146.
https://doi.org/10.1016/j.radonc.2009.06.008 
6. Takakura T, Koubuchi S, Uehara A, et al. Evaluation of beam-on time and number of breath-
holds using a flattening-filter-free beam with the deep inspiration breath-hold method in left-
sided breast cancer. Med Dosim. 2020;45(4):359-362.
https://doi.org/10.1016/j.meddos2020.05.002
7. Li XA, Tai A, Arthur DW, et al. Variability of target and normal structure delineation for
breast cancer radiotherapy: an RTOG multi-institutional and multiobserver study. Int J
Radiat Oncol Biol Phys. 2009;73(3):944-951. https://doi.org/10.1016/j.ijrobp.2008.10.034
8. Cossetti RD, Tyldesley SK, Speers CH, Zheng Y, Gelmon KA. Comparison of breast cancer
recurrence and outcome patterns between patients treated from 1986 to 1992 and from 2004
to 2008. J Clin Oncol. 2015;33(1):65-73. https://doi.org/10.1200/jco.2014.57.2461 
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Figures

Figure 1. Axial view of patient 1 shows the location of the cavity (red) and breast PTV (orange).

Figure 2. Frontal view of patient 1 shows the location of the cavity (red), breast PTV (orange),
and heart (pink).
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Figure 3. Dose volume histogram (DVH) comparisons for the PTV cavity (blue), Left Breast
Evaluation (orange), Left Lung (green), Heart (pink) for patient 1’s FFF (square markers) and
mixed energy (triangle markers) plans.
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Tables
Table 1. Physician-specified dose constraints for OAR evaluation.

Structures Constraints
Heart (left breast) Mean < 3.0 Gy
Heart (right breast) Mean < 1.0 Gy
LAD Maximum < 3.0 Gy
Ipsilateral Lung V20 < 30%
*Organs at risk (OAR); Volume of lung receiving 20 Gy (V20)

Table 2. Measured results comparing 10FFF and mixed energy.

Patient Breast Mixed Energy
Cavitymin
Separation V95% Weighting
(%)
(cm) (%) (6x:10x) (%)
Mixed 22 91.4 92.1 45.5:54.5
FFF 22 89 92.2
Mixed 22.3 95.2 95.4 49.2:50.8
FFF 22.3 90.2 90.7
Mixed 26.1 89.4 95.7 55.5:44.5
FFF 26.1 88.3 95.0
Mixed 24.5 91.6 94.3 57.8:42.2
FFF 24.5 87.5 93.9
Mixed 21 93.7 86.5 53.8:46.2
FFF 21 90.6 84.6
Mixed 25.8 92.8 94.7 49.4:50.6
FFF 25.8 90.6 97.3
Mixed 22.7 91 91.9 46.5:53.5
FFF 22.7 88.8 91.9
*FFF (Flattening Filter Free); Breast Tissue covered by 95% prescribed dose of 47.5Gy (Breast V 47.5);
Mixed energy 6x and 10x (Mixed); Minimum cavity dose (Cavitymin); Mixed Energy Weighting ratio
of 6MV to 10MV in percentage