Flattening filter free vs flattened beams for breast irradiation.
OBJECTIVE
Flattening filter free (FFF) beams offer the potential for a higher dose rate, shorter treatment time, and lower peripheral dose. To investigate their role in large-field treatments, this study compared flattened and FFF beams for breast irradiation.


METHODS
Ten left breast clinical plans comprising 2 tangential beams and a medially located 3-field simultaneous integrated boost (SIB) were replanned. Full intensity modulated radiotherapy (IMRT), hybrid IMRT, electronic tissue compensator (ETC), and multiple static field treatment plans were created for the elective breast volume using flattened and FFF beams, in combination with a 3-field IMRT SIB. Plan quality was assessed and delivery times were measured for all plans for 1 patient. Out-of-field doses were measured using an ionization chamber for an IMRT plan optimized on a corner of simple cubic phantom for both flattened and FFF beams.


RESULTS
For each technique, mean target volume metrics (planning target volume coverage, homogeneity, conformity) were typically within 3% for flattened and FFF beams. Larger mean differences in boost conformity favoring flattened hybrid (7.2%) and full IMRT (5.5%) plans may have reflected limitations in plan normalization. Calculated heart and ipsilateral lung doses were comparable; however, both flattened and FFF low-dose phantom measurements were substantially higher than calculated values, rendering the comparison of low dose in the contralateral breast uncertain. Beam delivery times were on average 31% less for FFF.


CONCLUSIONS
In general, target volume metrics for flattened and FFF plans were comparable. The planning system did not seem to allow for accurate peripheral dose evaluation. FFF was associated with a potentially shorter treatment time. All 4 IMRT techniques allowed FFF beams to generate acceptable plans for breast IMRT.
Department of Radiation Oncology, VU University Medical Center, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands. k.spruijt@vumc.nl
Kees H
KH
Spruijt
Max
M
Dahele
Johan P
JP
Cuijpers
Marloes
M
Jeulink
Derek
D
Rietveld
Ben J
BJ
Slotman
Wilko F A R
WF
Verbakel
D000465:Algorithms; D001940:Breast / Q000528:radiation effects; D001943:Breast Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy*; D005260:Female; D005374:Filtration / Q000295:instrumentation; D006321:Heart / Q000000981:diagnostic imaging / Q000528:radiation effects; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging / Q000528:radiation effects; D058958:Organs at Risk / Q000000981:diagnostic imaging / Q000528:radiation effects; D017785:Photons / Q000627:therapeutic use; D011829:Radiation Dosage; D011859:Radiography; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000295:instrumentation / Q000379:methods*; D013997:Time Factors; D047368:Tumor Burden