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,
FAAMD

Medical Dosimetry Program at the University of Wisconsin - La Crosse

Introduction
The components of intensity-modulated radiation therapy (IMRT) for treating lung
cancer encompass several crucial aspects; including established treatment protocols, radiation
dosage, average treatment duration, and the management of respiratory motion. The presence of
respiratory motion introduces a level of uncertainty in the treatment, thereby diminishing the
precision of thoracic radiation therapy. To mitigate this motion during IMRT sessions for lung
cancer, and to obtain optimal treatment, respiratory motion management methods are utilized.
This is an integral aspect of lung irradiation, essential for minimizing radiation exposure to
healthy tissue and nearby organs at risk (OAR). As a means of motion management, lung cancer
patients undergoing IMRT are asked to perform multiple breath-holding sequences while on the
treatment machine, which, in turn, extends their radiation treatment duration. Advances in IMRT
techniques and the elevated dose rate associated with flattening filter-free (FFF) beams offer a
promising solution to the challenge of managing respiratory motion1.
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
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patient motion management plans based on patient-specific characteristics, such as tumor

location, patient anatomy, and treatment delivery technique. 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.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.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 due to the decrease in time of treatment segments.7 This decreased treatment time
associated with the use of FFF-IMRT is a cornerstone in optimal radiation treatment. 8
Lung cancer patients undergoing IMRT are asked to perform multiple breath-holding
sequences while on the treatment machine, therefore making a reduction in treatment time
particularly beneficial.9 Researchers evaluated and compared several metrics in unison for this
case study. These metrics included treatment delivery time, along with dose to OAR, and volume
coverage of prescribed dose per QUANTEC guidelines. Researchers assesses the feasibility of
FFF-IMRT leading to a reduction in lung cancer treatment time of > 40%, while maintaining
OAR dose constraints and prescribed target metrics (H1A).
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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. During simulation, the radiation therapists instructed the patient on proper breathing
methods, determining an appropriate threshold and breath-hold time length for the patient.
Radiopaque markers were placed on the patient's external skin and/or immobilization device for
patient setup and triangulation. Three separate breath-hold scans were performed by the radiation
therapists to ensure reproducibility of the patient's breath-hold, obtained with a 3 mm thickness.
ABC was used as the respiratory motion management system. The patients had a soft clip placed
over their nose along with a tube inserted into their mouth to ensure their breathing could be
monitored by the ABC system.
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 include the bilateral lungs, heart, and spinal canal.10 The OAR contours were
reviewed by the radiation oncologist, who proceeded to contour the planning target volume
(PTV). The treatment planning goals included minimizing dose to the heart, contralateral lung,
and spinal canal while maximizing dose to the PTV (Figures 1&2).
Treatment Planning
During treatment planning, the medical dosimetrist established an isocenter based on the
radiopaque markers used during the simulation scan. After this location was selected on the TPS,
the medical dosimetrist began treatment planning using the PTV set by the radiation oncologist.
Each beam arrangement consisted of 2 full volumetric arcs therapy (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
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constraints used by the medical dosimetrist were in measurements of volume (V), and maximum
dose (Dmax) in centi-gray (cGy). The OAR dose constraints included V30 < 20% for the heart,
V20 < 7% for the contralateral lung, and maximum dose (cGy) at a point 0.03 cc < 45 Gy for the
spinal canal (Table 1). 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.
The mean tumor dose (MTD) was evaluated using centi-gray (cGy), with all patients'
plans prescribed between 4500-6500 cGy; the monitor units (MU) of each individual arc were
calculated to determine the actual beam on time for each technique. 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 maximum dose
within the spinal canal was assessed using cGy at a volume of 0.03 cc.
Plan Analysis & Evaluation
All plans met OAR objectives, as defined by clinical constraints and physician
references. A dose volume histogram (DVH) was used to evaluate each plan's target and OAR
dose, and presented a comparison between the 6FF and 6FFF plans for each patient (Figure 3).
Assessing the MTD demonstrated minor change for all 5 patient cases between the 6FF and
6FFF plans. Patient cases 1, 4, and 5 demonstrated an average of 1% higher MTD in the 6FFF
plans, while cases 2 and 3 demonstrated an average of 1% lower MTD (Table 2). However,
regardless of the minor changes in MTD, all targets still received tumor coverage of 100%
prescription dose covering 95% of PTV. By calculating the arcs’ MU divided by the dose rate, a
dose rate comparison could be seen; with the 6FF plan utilizing a dose rate at 600 MU/min,
while the 6FFF plans utilized a dose rate of 2000 MU/min. The average beam-on time for 6FFF
plans was reduced by 70% when compared to the 6FF plans; and included a dose rate roughly 3
times higher.
The contralateral lung V20 results showed minimal to no change in all 5 patient cases for
both 6FF and 6FFF techniques; the V20 value average was 3% for patient cases 3 and 4, and
ranged between 0-1% for cases 1, 2 and 5. The heart V30 results also demonstrated minimal to no
change for both 6FF and 6FFF techniques in all patient cases. When 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 cases 4 and 5 where
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the target and heart exhibited greater separation (Table 2). All patient cases met lung V 20 <7%
and heart V30 < 20% constraints. These results indicate that utilizing 6FFF technique will reduce
treatment time ≥ 40% compared to an FF technique, while maintaining constraints of OAR and
mean tumor dose.
Discussion
Lung cancer patients undergoing IMRT are asked to perform multiple breath-holding
sequences while on the treatment machine, thereby extending radiation treatment duration. The
results from this study indicate the usefulness of FFF-IMRT, in comparison to FF-IMRT, in a
reduction of average beam-on time by 70% and a reduction in overall treatment time of > 40%.
Furthermore, the adoption of FFF-IMRT also upholds the integrity of critical OAR dose levels
and maintains adherence to treatment constraints. Through the utilization of this treatment
option, an overall benefit can be appreciated by optimizing patient care through shorter treatment
times while ensuring the meticulous management of radiation to ensure safe and effective
treatment outcomes.
The AAPM has highlighted the importance of individualized patient motion management
since 2006 and continues to improve through recommendations of the AAPM Task Group 324
report from 2020.2 In conjunction with the recommendations from the AAPM, shorter treatment
times also translate to reduced discomfort for patients undergoing radiation therapy. This can
significantly enhance patient compliance with prescribed treatment regimens and improve their
overall experience, fostering better adherence to therapy and leading to improved treatment
outcomes. The precise control and maintenance of radiation doses to OAR is crucial for
minimizing long-term side effects and complications. FFF-IMRT's capability to maintain dose
constraints ensures that critical structures surrounding the target area receive minimal radiation
exposure, reducing the risk of adverse effects and enhancing patients' overall quality of life post-
treatment.
Conclusion
The success of FFF-IMRT in maintaining treatment efficacy while reducing treatment
time lays the foundation for further research and development in the field of radiation oncology.
This can lead to the creation of even more advanced treatment modalities and technologies,
continually improving patient care. This integration of FFF-IMRT into radiation oncology
practices not only exemplifies a technological advancement but also a significant step toward
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enhancing patient-centered care. The ability to reduce treatment time and maintain dose
constraints holds the potential to revolutionize the way radiation therapy is administered,
ultimately benefiting patients and healthcare facilities, improving outcomes overall.
While FFF-IMRT offers several advantages in radiation oncology, it is essential to
recognize its limitations. These limitations include data management challenges, time
constraints, issues related to construct validity and clinical implementation, resource demands,
and the need for further clinical evidence and guidelines. Healthcare facilities and clinicians must
consider these limitations when adopting FFF-IMRT and ensure that it is used judiciously in
appropriate clinical contexts. Future research studies in FFF-IMRT should aim to address these
areas to further refine and expand the clinical applications of this advanced radiation therapy
technique, ultimately improving patient care and outcomes in the field of radiation oncology.
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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
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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
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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) -
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https://doi.org/10.1002/mp.13267
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Figures

Figure 1. Frontal view of patient 5 showing the location of the PTV (purple) in relation to the
contralateral lung (orange) and heart (blue).

Figure 2. Axial view of patient 5 showing the location of the PTV (purple) in relation to the
contralateral lung (orange), heart (blue), and spinal cord (pink).
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Figure 3. Dose volume histogram (DVH) comparisons for the PTV (purple), spinal canal (pink),
heart (blue), and contralateral lung (orange) are shown for patient 5 for the 6FF plan (dashed
lines) and 6FFF plan (solid lines).
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Tables

Table 1. Dose limits serve as planning constraints for the organs at risk (OAR) in plan
evaluation.
Structures Constraints
Heart V30 < 20%
Contralateral Lung V20 < 7%
Spinal Canal Maximum Dose < 45 Gy
*Organs at risk (OAR); Volume of heart receiving 30 Gy (V30); Volume of lung receiving 20 Gy (V20); all constraints are from QUANTEC or
AAPM TG-101.

Table 2. Measured target metrics show a slight decrease in beam-on time when utilizing the
6FFF technique.
Mean
6 FF vs. Tumor Average Contralateral Heart V30
Patient 6FFF Dose Beam-On Lung V20 (%)
(MTD) Time (%)
(cGy) (seconds)
1 6 FF 6008.8 202.53 0.52 12.2
1 6 FFF 6159.5 60.80 0.60 12.5
2 6 FF 4594.7 72.15 1.2 17.5
2 6 FFF 4408 21.40 1.3 17.8
3 6 FF 6444.7 57.57 2.9 10.6
3 6 FFF 6126.5 17.17 2.8 10.9
4 6 FF 6920 75.45 3.1 1.9
4 6 FFF 7246 25.51 3.2 2.1
5 6 FF 6415.7 35.30 0.80 1.5
5 6 FFF 6816.3 10.66 0.85 1.8
*Flattening filter (FF); Flattening filter-free (FFF); Centigray (cGy); Volume of lung receiving 20 Gy (V20); Volume of heart receiving 30 Gy
(V30)