Evaluation of flattening-filter-free and flattening filter dosimetric and radiobiological criteria for lung SBRT: A volume-based analysis

Comparison between flattening filter and flattening filter-free photon beams in head and neck cancer patients using volumetric modulated arc therapy technique

This study aimed to evaluate the dosimetric and clinical outcomes of flattening filter (FF) versus flattening filter-free (FFF) beams in head and neck cancer (HNC) patients treated with volumetric modulated arc therapy (VMAT). Twenty-four patients with 70/59.4/54 Gy dose prescribed in 33 fractions with simultaneous integrated boost treatment were retrospectively analyzed to compare treatment delivery efficiency, target coverage, sparing of organs at risk (OARs), and remaining volume at risk (RVR) in two HNC groups (nasopharyngeal and oropharyngeal). Study findings indicate that FFF beams significantly reduce conformity index (CI) and homogeneity index (HI) by p-values (0.008, < 0.001, 0.002, 0.015) for PTV70 CI, PTV70 HI, PTV60 HI, and PTV54 HI, respectively. Gradient dose was significantly improved in FFF mode, and monitor units (MU) were increased (p < 0.001). In terms of OARs, the study revealed superior performance of FFF in most of structures and RVR especially in the oropharyngeal group. OARs sparing is notably enhanced for structures distant from the target (eyes, lenses, and optic pathway). Additionally, brainstem sparing shows significant improvement in oropharyngeal cases when using FFF plans (p = 0.046); however, FF plans demonstrate superior results in nasopharyngeal cases (p = 0.026). It is concluded that both FF and FFF photon beams are effective for treating HNC patients. VMAT plans using FFF mode offer clinically acceptable outcomes, demonstrating a significant reduction in gradient and integral dose. However, FF plans exhibit superior target homogeneity and reduced MU requirements. Therefore, the choice between these techniques should be based on a comprehensive evaluation of all relevant parameters.

Impact of flattening filter-free beams on remaining volume at risk in lung cancer treatment

Modern radiotherapy machines offer a new modality, like flattening filter-free beam (FFF), which is used especially in stereotactic body radiation therapy (SBRT) to reduce treatment time. The remaining volume at risk (RVR) is known as undefined normal tissue, and assists in evaluating late effects such as carcinogenesis. This study aimed to compare the effects of flattening and un-flattened beams on RVR in lung cancer treated by conventional doses using volumetric modulated arc therapy (VMAT) and intensity modulated radiation therapy (IMRT). Twenty-three lung cancer patients with a prescribed dose of 60 Gy delivered in 30 fractions were selected retrospectively. Four treatment plans were generated for each case (VMAT FF, VMAT FFF, IMRT FF and IMRT FFF). Mean doses to RVR and volumes that received low doses (V15Gy, V10Gy and V5Gy) were introduced as RVR evaluation parameters. Variance percentage comparison between flattening filter (FF) and FFF for the RVR evaluation parameters gave 2.38, 1.10, 1.80 and 2.22 for VMAT, and 1.73, 1.18, 1.62 and 1.81 for IMRT. In contrast, VMAT and IMRT RVR evaluation parameters resulted in variance percentage differences of 10.29, 5.02, - 8.84 and - 4.82 for FF, and 11.18, 4.96, - 8.59 and - 4.48for FFF. It is concluded that in terms of RVR evaluation parameters, FFF is clinically beneficial compared to FF for RVR, due to the decrease in mean RVR dose and low-dose irradiated RVR volume. Furthermore, VMAT is preferred in the mean RVR dose and V15Gy, while IMRT is better in V10Gy and V5Gy for RVR.

Stereotactic body radiotherapy for early-stage lung cancer: a systematic review on the choice of photon energy and linac flattened/unflattened beams

SBRT is an effective local treatment for patients with early-stage non-small cell lung cancer (NSCLC). This treatment is currently used in patients who have poor lung function or who decline surgery. As SBRT usually has small PTV margins, reducing the beam-on-time (BOT) is beneficial for accurate dose delivery by minimising intrafraction motion as well as improved patient comfort. Removal of the linear accelerator flattening filter can provide a higher dose rate which results in a faster treatment. In addition, the choice of photon energy can also affect the dose distribution to the target and the organs-at-risk (OAR). In this systematic review, studies analysing the choice of various photon beam energies, with a flattening filter or flattening filter free (FFF), were compared for their overall dosimetric benefit in the SBRT treatment for early-stage NSCLC. It was found that FFF treatment delivers a comparatively more conformal dose distribution, as well as a better homogeneity index and conformity index, and typically reduces BOT by between 30 and 50%. The trade-off may be a minor increase in monitor units for FFF treatment found in some studies but not others. Target conformity and OAR sparing, particularly lung doses appear better with 6MV FFF, but 10MV FFF was marginally more advantageous for skin sparing and BOT reduction. The favourable beam modality for clinical use would depend on the individual case, for which tumour size and depth, radiotherapy technique, as well as fractionation scheme need to be taken into account.

Key changes in the future clinical application of ultra-high dose rate radiotherapy

Ultra-high dose rate radiotherapy (FLASH-RT) is an external beam radiotherapy strategy that uses an extremely high dose rate (≥40 Gy/s). Compared with conventional dose rate radiotherapy (≤0.1 Gy/s), the main advantage of FLASH-RT is that it can reduce damage of organs at risk surrounding the cancer and retain the anti-tumor effect. An important feature of FLASH-RT is that an extremely high dose rate leads to an extremely short treatment time; therefore, in clinical applications, the steps of radiotherapy may need to be adjusted. In this review, we discuss the selection of indications, simulations, target delineation, selection of radiotherapy technologies, and treatment plan evaluation for FLASH-RT to provide a theoretical basis for future research.