Dosimetric comparison of flattened and unflattened beams for stereotactic body radiation therapy: Impact of the size of the PTV on dynamic conformal arc and volumetric modulated arc therapy

Treating early-stage centrally-located non-small cell lung cancer with DCAT-SBRT in centers lacking the VMAT technique: a comprehensive study

Background

Volumetric-modulated arc therapy (VMAT) may have the highest overall performance for stereotactic body radiotherapy (SBRT) treatment of inoperable early-stage NSCLC. However, in centers lacking the VMAT technique, the dynamic conformal arc therapy (DCAT) technique is potentially the best option for small and rounded NSCLC-SBRT. Therefore, we will comprehensively analyze the advantages of the DCAT versus the other techniques except VMAT in terms of dosimetry, plan complexity, delivery time, γ-passing rates and the interplay effect.

Methods

36 patients with early-stage centrally located NSCLC with PTV volumes < 65 cc were enrolled. All patients were redesigned with 50Gy/5f, and 100% of the prescribed dose was normalized to cover 95% of the PTV. The other two delivery techniques compared to the DCAT technique include 3-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT), which use the same parameters for all three techniques.

Results

The dosimetric parameters of the 3-group plans all met the RTOG 0813 protocol. Unsurprisingly, plan complexity parameters such as segments and MUs were significantly reduced in the DCAT plans by 159.56 and 925.90 compared to the IMRT plans, respectively (all P < 0.001). The delivery time of the DCAT plans was the least of 164.51 s (all P < 0.05). Compared to the IMRT plans, the γ-passing rates were higher in the DCAT plans (P < 0.001), with the most significant difference of 6.01% in the (2%, 1 mm) criteria. As for the interplay effect, the mean dose difference (MDD) in the DCAT plans was as good as the 3DCRT plans at different respiratory amplitudes but better than the IMRT plans (all P < 0.05), and the MDD of DCAT plans did not exceed 3% in all respiratory amplitude.

Conclusion

In centers lacking the VMAT technique, implementing SBRT treatment based on the DCAT technique for inoperable early-stage centrally-located NSCLC patients with PTV volumes < 65 cc achieves better treatment efficiency and delivery accuracy while maintaining the plan quality.

Stereotactic body radiotherapy with volumetric intensity-modulated arc therapy and flattening filter-free beams: dosimetric considerations

PURPOSE

The present study comparatively evaluates the impact of energy-matched flattening filter-free (FFF) photon beams with different energy levels on the physical-dosimetric quality of lung and liver stereotactic body radiotherapy (SBRT) treatment plans.

METHODS

For this purpose, 54 different lung and liver lesions from 44 patients who had already received SBRT combined with volumetric modulated arc therapy (VMAT) were included in this retrospective planning study. Planning computed tomography scans already available were used for the renewed planning with 6 MV, 6 MV-FFF, 10 MV, and 10 MV-FFF under constant planning objectives. The treatment delivery data, dosimetric distributions, and dose-volume histograms as well as parameters such as the conformity index and gradient indices were the basis for the evaluation and comparison of treatment plans.

RESULTS

A significant reduction of beam-on time (BOT) was achieved due to the high dose rates of FFF beams. In addition, we showed that for FFF beams compared to flattened beams of the same energy level, smaller planning target volumes (PTV) require fewer monitor units (MU) than larger PTVs. An equal to slightly superior target volume coverage and sparing of healthy tissue as well as organs at risk in both lung and liver lesions were found. Significant differences were seen mainly in the medium to lower dose range.

CONCLUSION

We found that FFF beams together with VMAT represent an excellent combination for SBRT of lung or liver lesions with shortest BOT for 10 MV-FFF but significant dose savings for 6 MV-FFF in lung lesions.

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.

A novel lung SBRT treatment planning: Inverse VMAT plan with leaf motion limitation to ensure the irradiation reproducibility of a moving target

This study exposed the implementation of a novel technique (VMATLSL) for the planning of moving targets in lung stereotactic body radiation therapy (SBRT). This new technique has been compared to static conformal radiotherapy (3D-CRT), volumetric-modulated arc therapy (VMAT), and dynamic conformal arc (DCA). The rationale of this study was to lower geometric complexity (54.9% lower than full VMAT) and hence ensure the reproducibility of the treatment delivery by reducing the risk for interplay errors induced by respiratory motion. Dosimetry metrics were studied with a cohort of 30 patients. Our results showed that leaf speed limitation provided conformal number (CN) close to the VMAT (median CN of VMATLSL is 0.78 vs 0.82 for full VMAT) and was a significant improvement on 3D-CRT and DCA with segment-weight optimized (respectively 0.55 and 0.57). This novel technique is an alternative to VMAT or DCA for lung SBRT treatments, combining independence from the patient's breathing pattern, from the size and amplitude of the lesion, free from interplay effect, and with dosimetry metrics close to the best that could be achieved with full VMAT.

Dosimetric comparison of mDCAT and VMAT techniques according to 6MV-FFF and 10MV-FFF energies in patients with single adrenal metastasis

OBJECTIVE

To compare dosimetric and radiobiological terms of modified dynamic conformal arc therapy (mDCAT) and volumetric modulated arc therapy (VMAT) techniques using different flattening-filter free (FFF) energies in patients with single adrenal metastasis.

METHODS

In this study, plans were prepared for 10 patients drawing on the mDCAT and VMAT techniques with 6MV-FFF and 10MV-FFF energies. Target volume doses, biological effective doses (BED), quality indices, Monitor Unit (MU), number of segments, beam-on time and critical organ doses were compared in the plans.

RESULTS

Plans with the significantly lower gradient index (GI) and conformity index (CI) values were obtained with 6MV-FFF energy VMAT planning (p < 0.05). The higher values were obtained for dose to 95% of internal target volume (ITVD95), ITVD95-BED10 with 10MV-FFF energy VMAT planning, whereas lower results were obtained for high dose spillage (HDS%) values (p < 0,05). With 10MV-FFF energy, HDS% values were 21.1% lower in VMAT plans and 5.6% lower in mDCAT plans compared to 6MV-FFF energy. Plans with approximately 50% fewer segments were obtained in mDCAT plans than VMAT plans (p < 0,05). Beam-on time values with mDCAT was 1.84 times lower when 6MV-FFF energies were analyzed, and 2.11 times lower when 10MV-FFF was analyzed (p < 0,05). Additionally, when 6MV-FFF and 10MV-FFF energies were examined, MU values with mDCAT were 2.1 and 2.5 times lower (p < 0,05). In general, the smaller the target volume size, the greater the differences between MU and beam-on time values mDCAT and VMAT.

CONCLUSIONS

The study results implied that VMAT enabled to offer significantly more conformal SBRT plans with steeper dose fall-off beyond the target volume for single adrenal metastasis than the mDCAT, which attained at the cost of significantly higher MU and beam-on times. Especially with 10MV-FFF energy mDCAT plans, low-dose-bath zones can be reduced, and shorter-term treatments can be implemented with large segments. In adrenal gland SBRT, higher effective doses can be achieved with the right energy and technique, critical organ doses can be reduced, thus increasing the possibility of local control of the tumor with low toxicity.

Comparison of Moderate Hypofractionated Volumetric-Modulated Arc Therapy Plans With and Without Flattening Filter for Localized Prostate Cancer

Background/Aim The aim of this study was to compare volumetric-modulated arc therapy (VMAT) radiation plans between conventional VMAT with flattening filter (cFF-VMAT) and flattening filter-free VMAT (FFF-VMAT) for localized prostate cancer. Materials and methods Ten patients with localized prostate cancer who underwent cFF-VMAT at Yokosuka General Hospital Uwamachi, Yokosuka, Japan, from July 2020 to October 2020 were enrolled. Dose-volume histogram (DVH) parameters of the target volume, normal organs, monitor units (MU), and beam-on time (BOT) were compared between cFF-VMAT and FFF-VMAT plans. Results No significant difference was observed for DVH parameters for the target volume. No significant difference was observed in all parameters for the bladder and rectum between the cFF-VMAT and FFF-VMAT groups. The mean values of MU were 686 ± 52 and 784 ± 80 in cFF-VMAT and FFF-VMAT, respectively (p < 0.001). The mean BOT was 97.0 ± 6.6 s and 72.9 ± 1.4 s for cFF-VMAT and FFF-VMAT, respectively (p < 0.001). Conclusion DVH parameters of the target volume and normal organs were not significantly different between the cFF-VMAT and FFF-VMAT plans. In FFF-VMAT, MU was significantly higher, and the BOT was significantly shorter than those in cFF-VMAT.

Evaluation of inter- and intra-fraction 6D motion for stereotactic body radiation therapy of spinal metastases: influence of treatment time

Background

The objective of this study was to analyze the amplitude of translational and rotational movements occurring during stereotactic body radiotherapy (SBRT) of spinal metastases in two different positioning devices. The relevance of intra-fractional imaging and the influence of treatment time were evaluated.

Methods

Twenty patients were treated in the supine position either (1) on a body vacuum cushion with arms raised and resting on a clegecel or (2) on an integrated SBRT solution consisting of a SBRT table top, an Orfit™ AIO system, and a vacuum cushion. Alignments between the cone beam computed tomography (CBCT) and the planning computed tomography allowed corrections of inter- and intra-fraction positional shifts using a 6D table. The absolute values of the translational and rotational setup errors obtained for 329 CBCT were recorded. The translational 3D vector, the maximum angle, and the characteristic times of the treatment fractions were calculated.

Results

An improvement in the mean (SD) inter-fraction 3D vector (mm) from 7.8 (5.9) to 5.9 (3.8) was obtained by changing the fixation devices from (1) to (2) (p < 0.038). The maximum angles were less than 2° for a total of 87% for (1) and 96% for (2). The mean (SD) of the intra-fraction 3D vectors (mm) was lower for the new 1.1 (0.8) positioning fixation (2) compared to the old one (1) 1.7 (1.7) (p = 0.004). The angular corrections applied in the intra-fraction were on average very low (0.4°) and similar between the two systems. A strong correlation was found between the 3D displacement vector and the fraction time for (1) and (2) with regression coefficients of 0.408 (0.262–0.555, 95% CI) and 0.069 (0.010–0.128, 95% CI), respectively. An accuracy of 1 mm would require intra-fraction imaging every 5 min for both systems. If the expected accuracy was 2 mm, then only system (2) could avoid intra-fractional imaging.

Conclusions

This study allowed us to evaluate setup errors of two immobilization devices for spine SBRT. The association of inter- and intra-fraction imaging with 6D repositioning of a patient is inevitable. The correlation between treatment time and corrections to be applied encourages us to move toward imaging modalities which allow a reduction in fraction time.

Progress and prospects of flattening filter free beam technology in radiosurgery and stereotactic body radiotherapy

The aim of this work is to summarize and evaluate the current status of knowledge on flattening filter free (FFF) beams and their applications in stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT). A PubMed search was undertaken in order to identify relevant publications using FFF and stereotactic radiotherapy as keywords. On a clinical aspect, lung tumors treated with FFF SBRT show promising results in terms of local control and overall survival with acute toxicities consistent with those that occur with standard radiotherapy. Beside lung, SBRT is suitable for different anatomical sites such as liver, prostate, cervix, etc. offering similar results: reduced treatment time, good tumor control and mild acute toxicities. Regarding brain tumors, the employment of SRS with FFF beams significantly reduces treatment time and provides notable normal tissue sparing due to the sharp dose fall-off outside the tumor.

Dosimetric study between a single isocenter dynamic conformal arc therapy technique and Gamma Knife radiosurgery for multiple brain metastases treatment: impact of target volume geometrical characteristics

Purpose

To compare linac-based mono-isocentric radiosurgery with Brainlab Elements Multiple Brain Mets (MBM) SRS and the Gamma Knife using a specific statistical method and to analyze the dosimetric impact of the target volume geometric characteristics. A dose fall-off analysis allowed to evaluate the Gradient Index relevancy for the dose spillage characterization.

Material and methods

Treatments were planned on twenty patients with three to nine brain metastases with MBM 2.0 and GammaPlan 11.0. Ninety-five metastases ranging from 0.02 to 9.61 cc were included. Paddick Index (PI), Gradient Index (GI), dose fall-off, volume of healthy brain receiving more than 12 Gy (V_12Gy) and DVH were used for the plan comparison according to target volume, major axis diameter and Sphericity Index (SI). The multivariate regression approach allowed to analyze the impact of each geometric characteristic keeping all the others unchanged. A parallel study was led to evaluate the impact of the isodose line (IDL) prescription on the MBM plan quality.

Results

For mono-isocentric linac-based radiosurgery, the IDL around 70–75% was the best compromise found. For both techniques, the GI and the dose fall-off decreased with the target volume. In comparison, PI was slightly improved with MBM for targets < 1 cc or SI > 0.78. GI was improved with GP for targets < 2.5 cc. The V_12Gy was higher with MBM for lesions > 0.4 cc or SI < 0.84 and exceeded 10 cc for targets > 5 cc against 6.5 cc with GP. The presence of OAR close to the PTV had no impact on the dose fall off values. The dose fall-off was higher for volumes < 3.8 cc with GP which had the sharpest dose fall-off in the infero-superior direction up to 30%/mm. The mean beam-on time was 94 min with GP against 13 min with MBM.

Conclusions

The dose fall-off and the V_12Gy were more relevant indicators than the GI for the low dose spillage assessment. Both evaluated techniques have comparable plan qualities with a slightly improved selectivity with MBM for smaller lesions but with a healthy tissues sparing slightly favorable to GP at the expense of a considerably longer irradiation time. However, a higher healthy tissue exposure must be considered for large volumes in MBM plans.

Effectiveness of robust optimization in volumetric modulated arc therapy using 6 and 10 MV flattening filter-free beam therapy planning for lung stereotactic body radiation therapy with a breath-hold technique

We investigated the feasibility of a robust optimization with 6 MV X-ray (6X) and 10 MV X-ray (10X) flattening filter-free (FFF) beams in a volumetric modulated arc therapy (VMAT) plan for lung stereotactic body radiation therapy (SBRT) using a breath-holding technique. Ten lung cancer patients were selected. Four VMAT plans were generated for each patient; namely, an optimized plan based on the planning target volume (PTV) margin and a second plan based on a robust optimization of the internal target volume (ITV) with setup uncertainties, each for the 6X- and 10X-FFF beams. Both optimized plans were normalized by the percentage of the prescription dose covering 95% of the target volume (D95%) to the PTV (1050 cGy × 4 fractions). All optimized plans were evaluated using perturbed doses by specifying user-defined shifted values from the isocentre. The average perturbed D99% doses to the ITV, compared to the nominal plan, decreased by 369.1 (6X-FFF) and 301.0 cGy (10X-FFF) for the PTV-based optimized plan, and 346.0 (6X-FFF) and 271.6 cGy (10X-FFF) for the robust optimized plan, respectively. The standard deviation of the D99% dose to the ITV were 163.6 (6X-FFF) and 158.9 cGy (10X-FFF) for the PTV-based plan, and 138.9 (6X-FFF) and 128.5 cGy (10X-FFF) for the robust optimized plan, respectively. Robust optimized plans with 10X-FFF beams is a feasible method to achieve dose certainty for the ITV for lung SBRT using a breath-holding technique.

Dosimetric comparison of dynamic conformal arc integrated with segment shape optimization and variable dose rate versus volumetric modulated arc therapy for liver SBRT

Purpose

The aim is a dosimetric comparison of dynamic conformal arc integrated with the segment shape optimization and variable dose rate (DCA_SSO_VDR) versus VMAT for liver SBRT and interaction of various treatment plan quality indices with PTV and degree of modulation (DoM) for both techniques.

Material

Twenty-five patients of liver SBRT treated using the VMAT technique were selected. DCA_SSO_VDR treatment plans were also generated for all patients in Monaco TPS using the same objective constraint template and treatment planning parameters as used for the VMAT technique. For comparison purpose, organs at risk (OARs) doses and treatment plans quality indices, such as maximum dose of PTV (D_max%), mean dose of PTV (D_mean%), maximum dose at 2 cm in any direction from the PTV (D_2cm%), total monitor units (MU's), gradient index R_50%, degree of modulation (DoM), conformity index (CI), homogeneity index (HI), and healthy tissue mean dose (HTMD), were compared.

Results

Significant dosimetric differences were observed in several OARs doses and lowered in VMAT plans. The D_2cm%, R_50%, CI, HI and HTMD are dosimetrically inferior in DCA_SSO_VDR plans. The higher DoM results in poor dose gradient and better dose gradient for DCA_SSO_VDR and VMAT treatment plans, respectively.

Conclusions

For liver SBRT, DCA_SSO_VDR treatment plans are neither dosimetrically superior nor better alternative to the VMAT delivery technique. A reduction of 69.75% MU was observed in DCA_SSO_VDR treatment plans. For the large size of PTV and high DoM, DCA_SSO_VDR treatment plans result in poorer quality.

Comparison of radiotherapy techniques with flattening filter and flattening filter-free in lung radiotherapy according to the treatment volume size

In external radiotherapy (RT), the use of flattening filter-free (FFF) radiation beams obtained by removing the flattening filter (FF) in standard linear accelerators is rapidly increasing, and the benefits of clinical use are the issue of research. Advanced treatment techniques have increased the interest in the operation of linear accelerators in FFF mode. The differences of the beams with non-uniform dose distribution created by removing FF compared to the beams with uniform dose distribution used as a standard were examined. These differences were compared in the treatment plans of lung patients who have different planning target volumes (PTV). Clinac IX linear accelerator units were used. Twenty patients with previously completed treatment were divided into two groups depending on the size of the target volume. All patients underwent two different intensity-modulated RT (IMRT) plans using FF and FFF beams. The Wilcoxon Signed-Rank test was used to compare two different techniques (Significance p < 0.05). There was no statistically significant difference between the two techniques when looking at the D2%(Gy), D98%(Gy), D50%(Gy), homogeneity (HI), and conformity index (CI) data for both groups. When the critical organ doses were evaluated, there was a statistically significant difference only in the V20(%) values of the lungs, but these differences were not very large. Monitor unit (MU) data were found to be lower in FF planning, and treatment time was lower in FFF planning. Except for shorter treatment times, and of the lungs V20(%) value, in standard fractionated RT of lung cancer, there was no significant difference between the use of FFF and FF techniques for large and small target volumes.

Comparison of treatment plan quality of VMAT for esophageal carcinoma with: flattening filter beam versus flattening filter free beam

Purpose: To investigate the difference in treatment plan quality of volumetric modulated arc treatment (VMAT) for esophageal carcinoma with flattening filter beam (FF) and flattening filter free beam (FFF). Material and methods: A total of fifty-six treatment plans were generated for twenty eight esophageal carcinoma patients with flattening filter beam and flattening filter free beam, using same optimal parameters. The homogeneity index (HI) and conformal index (CI) of targets, and some special points on Dose-Volume Histogram (DVH) curves were used to compare the plan quality. The coverage volumes of 45 Gy, 30 Gy and 20 Gy outside targets (V45Gy, V30Gy and V20Gy ) were used to compare the targets peripheral dose. The MU numbers, measured delivery time and averaged dose rates were used to evaluate the delivery efficiency of treatment plans. Results: A significant decreasing in peripheral dose around targets was found using FFF beams while the dose distributions in targets were equivalent to the plans with FF beams. V45Gy, V30Gy and V20Gy were decreased by 6.46%, 88.18% and 4.40%, respectively. A significant increase in MUs and decrease in treatment time were also found in delivery test. The average MUs was increased by 21.83% and the average treatment time was reduced by down to 11.9%. Conclusions: For esophageal carcinoma, the research showed that the treatment plans with FFF beams could get comparable dose distribution in targets and could significantly reduce the peripheral dose around targets compared to the plans with FF beams.

Editorial: The role of medical physics in lung SBRT

Stereotactic body radiation therapy (SBRT) has become a standard treatment for non-operable patients with early stage non-small cell lung cancer (NSCLC). In this context, medical physics community has largely helped in the starting and the growth of this technique. In fact, SBRT requires the convergence of many different features for delivering large doses in few fractions to small moving target in an heterogeneous medium. The special issue of last month, was focused on the different physics challenges in lung SBRT. Eleven reviews were presented, covering: imaging for treatment planning and for treatment assessment; dosimetry and planning optimization; treatment delivery possibilities; image guidance during delivery; radiobiology. The current cutting edge role of medical physics was reported. We aimed to give a complete overview of different aspects of lung SBRT that would be of interest to both physicists implementing this technique in their institutions and more experienced physicists that would be inspired to start research projects in areas that still need further developments. We also feel that the role that medical physicists have played in the development and safe implementation of SBRT, particularly in lung region, can be taken as an excellent example to be translated to other areas, not only in Radiation Oncology but also in other health sectors.

Improvement of conformal arc plans by using deformable margin delineation method for stereotactic lung radiotherapy

PURPOSE

Stereotactic body radiotherapy (SBRT) is an established treatment technique in the management of medically inoperable early stage non-small cell lung cancer (NSCLC). Different techniques such as volumetric modulated arc (VMAT) and three-dimensional conformal arc (DCA) can be used in SBRT. Previously, it has been shown that VMAT is superior to DCA technique in terms of plan evaluation parameters. However, DCA technique has several advantages such as ease of use and considerable shortening of the treatment time. DCA technique usually results in worse conformity which is not possible to ameliorate by inverse optimization. In this study, we aimed to analyze whether a simple method - deformable margin delineation (DMD) - improves the quality of the DCA technique, reaching similar results to VMAT in terms of plan evaluation parameters.

METHODS

Twenty stage I-II (T1-2, N0, M0) NSCLC patients were included in this retrospective dosimetric study. Noncoplanar VMAT and conventional DCA plans were generated using 6 MV and 10 MV with flattening filter free (FFF) photon energies. The DCA plan with 6FFF was calculated and 95% of the PTV was covered by the prescription isodose line. Hot dose regions (receiving dose over 100% of prescription dose) outside PTV and cold dose regions (receiving dose under 100% of prescription dose) inside PTV were identified. A new PTV (PTV-DMD) was delineated by deforming PTV margin with respect to hot and cold spot regions obtained from conventional DCA plans. Dynamic multileaf collimators (MLC) were set to PTV-DMD beam eye view (BEV) positions and the new DCA plans (DCA-DMD) with 6FFF were generated. Three-dimensional (3D) dose calculations were computed for PTV-DMD volume. However, the prescription isodose was specified and normalized to cover 95% volume of original PTV. Several conformity indices and lung doses were compared for different treatment techniques.

RESULTS

DCA-DMD method significantly achieved a superior conformity index (CI), conformity number (CIPaddick ), gradient index (R50% ), isodose at 2 cm (D2 cm ) and external index (CΔ) with respect to VMAT and conventional DCA plans (P < 0.05 for all comparisons). CI ranged between 1.00-1.07 (Mean: 1.02); 1.00-1.18 (Mean: 1.06); 1.01-1.23 (Mean 1.08); 1.03-1.29 (Mean: 1.15); 1.04-1.29 (Mean: 1.18) for DCA-DMD-6FFF, VMAT-6FFF, VMAT-10FFF DCA-6FFF and DCA-10FFF respectively. DCA-DMD-6FFF technique resulted significantly better CI compared to others (P = 0.002; < 0.001; < 0.001; < 0.001). R50% ranged between 3.22-4.74 (Mean: 3.99); 3.24-5.92 (Mean: 4.15) for DCA-DMD-6FFF, VMAT-6FFF, respectively. DCA-DMD-6FFF technique resulted lower intermediate dose spillage compared to VMAT-6FFF, though the difference was statistically insignificant (P = 0.32). D2 cm ranged between 35.7% and 67.0% (Mean: 53.2%); 42.1%-79.2% (Mean: 57.8%) for DCA-DMD-6FFF, VMAT-6FFF respectively. DCA-DMD-6FFF have significantly better and sharp falloff gradient 2 cm away from PTV compared to VMAT-6FFF (P = 0.009). CΔ ranged between 0.052 and 0.140 (Mean: 0.085); 0,056-0,311 (Mean: 0.120) for DCA-DMD, VMAT-6FFF, respectively. DCA-DMD-6FFF have significantly improved CΔ (P = 0.002). VMAT- V20 Gy , V2.5 Gy and mean lung dose (MLD) indices are calculated to be 4.03%, 23.83%, 3.42 Gy and 4.19%, 27.88%,3.72 Gy, for DCA-DMD-6FFF and DCA techniques, respectively. DCA-DMD-6FFF achieved superior lung sparing compared to DCA technique. DCA-DMD-6FFF method reduced MUs 44% and 33% with respect to VMAT-6FFF and 10FFF, respectively, without sacrificing dose conformity (P < 0.001; P < 0.001).

CONCLUSIONS

Our results demonstrated that DCA plan evaluation parameters can be ameliorated by using the DMD method. This new method improves DCA plan quality and reaches similar results with VMAT in terms of dosimetric parameters. We believe that DCA-DMD is a simple and effective technique for SBRT and can be preferred due to shorter treatment and planning time.