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Gill A, Hirst AL, Rowshanfarzad P, Gill S, Bucknell N, Dass J, Sabet M. Stereotactic body radiotherapy for early-stage lung cancer: a systematic review on the choice of photon energy and linac flattened/unflattened beams. Radiat Oncol 2024; 19:1. [PMID: 38167095 PMCID: PMC10762943 DOI: 10.1186/s13014-023-02392-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Abstract
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.
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Affiliation(s)
- Ashlesha Gill
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA, 6009, Australia.
| | - Andrew L Hirst
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Pejman Rowshanfarzad
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA, 6009, Australia
| | - Suki Gill
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA, 6009, Australia
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Nicholas Bucknell
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, 3000, Australia
| | - Joshua Dass
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Mahsheed Sabet
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA, 6009, Australia
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
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Choi DH, Kim JS, Lee R, Ahn SH, Ahn WS. Dosimetric verification of annual quality assurance for a linear accelerator using a transmission type detector. Sci Rep 2023; 13:17994. [PMID: 37865666 PMCID: PMC10590446 DOI: 10.1038/s41598-023-45114-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/16/2023] [Indexed: 10/23/2023] Open
Abstract
The purpose of our study is to establish an efficient quality assurance (QA) procedure using a transmission-type detector (IBA, Stealth chamber), a reference signal detector, as a field chamber. Relative dosimetry items, including monitor unit linearity, output constancy based on dose rate and field size, and output factor were measured and compared with results obtained from the Farmer-type chamber (IBA, Wellhofer, FC65-G). Moreover, output for each field size was measured to assess its applicability to small fields. Results using the Stealth chamber were in good agreement with the FC65-G within 1.0%, except for output constancy according to gantry angle, which had a 1.1% error rate for the Stealth chamber and 2.7% for the FC65-G. Differences of up to - 6.26% output factor were observed for the Stealth chamber and up to - 0.56% for the CC-13 ionization chamber (IBA) in the 3 × 3 cm2 field. Our study confirmed the possibility of using Stealth chambers for relative dosimetry measurement in QA.
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Affiliation(s)
- Dong Hyeok Choi
- Department of Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Medical Physics and Biomedical Engineering Lab (MPBEL), Yonsei University College of Medicine, Seoul, South Korea
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Sung Kim
- Department of Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Medical Physics and Biomedical Engineering Lab (MPBEL), Yonsei University College of Medicine, Seoul, South Korea
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Rena Lee
- Department of Biomedical Engineering, School of Medicine, Ewha Womans University, Seoul, South Korea
| | - So Hyun Ahn
- Ewha Medical Research Institute, School of Medicine, Ewha Womans University, Seoul, South Korea.
| | - Woo Sang Ahn
- Department of Radiation Oncology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, South Korea.
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Wu J, Song H, Li J, Tang B, Wu F. Evaluation of flattening-filter-free and flattening filter dosimetric and radiobiological criteria for lung SBRT: A volume-based analysis. Front Oncol 2023; 13:1108142. [PMID: 36761961 PMCID: PMC9903338 DOI: 10.3389/fonc.2023.1108142] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/06/2023] [Indexed: 01/26/2023] Open
Abstract
Introduction The use of volumetric modulated arc therapy (VMAT) with flattening-filter-free (FFF) beams is becoming more prevalent in lung cancer stereotactic body radiotherapy (SBRT). The aim in this study was to assess the impact of dosimetric and radiobiological differences between FFF and flattening filter (FF) beams for lung SBRT based on the target volume. Methods A total of 198 lung stereotactic body radiation therapy treatment plans with FFF beams and FF beams were retrospectively selected for this study. For all plans, the prescribed dose was 50 Gy/5 fractions, and the dose volume histogram (DVH) for the target and organs at risk (OAR) and the normal tissue complication probability (NTCP) of the lung were recorded and compared. Moreover, monitor units (MUs), the beam on-time and the treatment time were evaluated. Results The study was performed following the Radiation Therapy Oncology Group (RTOG) 0813 and 0915 protocols. No significant differences in D90, coverage rate (CR) or conformity index (CI) of the target were observed between FFF beams and FF beams (p>0.05). The D2, R50% and gradient index (GI) for the target improved with FFF beams compared with FF beams (p<0.05). FFF beams also significantly reduced the dose for the lung, heart, spinal cord, esophagus and NTCP of the lung (p<0.05), compared with FF beams. However, there was no significant difference in sparing of the trachea (p>0.05). The mean MUs, beam on-time and treatment time were 1871 ± 278 MUs, 3.2 ± 0.2 min and 3.9 ± 0.3 min for FFF beams, and 1890 ± 260 MUs, 4.2 ± 0.3 min and 4.8 ± 0.4 min for FF beams, respectively. Discussion The FFF beam technique for lung SBRT with VMAT results in a better dose fall-off, better dose-sparing of OAR, lower NTCP of the lung and a shorter beam on-time compared with the FF beam technique. Additionally, the improvement in target and OAR-sparing for FFF beams was increased with increasing target volume.
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Affiliation(s)
- Junxiang Wu
- Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Hongchang Song
- Department of Oncology, Xichang People’s Hospital, Xichang, China
| | - Jie Li
- Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Bin Tang
- Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Fan Wu
- Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China,*Correspondence: Fan Wu,
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Poolnapol V, Sanghangthum T, Keawsamur M. Impact of Dosimetric Parameters on Interplay Effects in 6 MV Flattening Filter-Free Photon Beams to Treat Lung Cancer. J Med Phys 2022; 47:20-26. [PMID: 35548034 PMCID: PMC9084591 DOI: 10.4103/jmp.jmp_63_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 01/15/2022] [Accepted: 01/15/2022] [Indexed: 11/30/2022] Open
Abstract
CONTEXT Interplay effects have become the significant problem in lung cancer radiotherapy. Since these effects yield dose variation within the target and surrounding tissues. AIM The aim of this study is to investigate the effect of the dosimetric parameters of interplay effects in 6 MV flattening filter-free (FFF) photon beams for lung cancer. SETTINGS AND DESIGN This study performed planning, measurement, and data analysis sections for examining different breathing amplitudes and phases, doses, dose rates, field sizes, and fractionations. SUBJECTS AND METHODS Standard and clinical plans were created on the eclipse treatment planning system. The static and dynamic measurements were performed using a robotic platform and two-dimensional (2D) diode array. The gamma passing rates were defined as the percent of dose variation caused by the interplay effects. STATISTICAL ANALYSIS USED Unpaired t-test. RESULTS The outcomes showed three trends between gamma passing rates (γ) and dosimetric parameters. First, a decreasing trend was breathing amplitudes. The lowest γ of maximum amplitudes (2 cm) in both one dimensional and 2D were <25%. Second, an increasing trend was field sizes. The lowest γ of minimum field size (4 cm × 4 cm2) was <55%. Third, constant outcomes were breathing phases, doses, dose rates, and a number of fractions. The γ values of these factors were 53.1%, 55.1%, 34.7%, and 36.7%, respectively. CONCLUSIONS Lung tumor motion-induced interplay effects in 6 MV FFF photon beams are more pronounced for higher breathing amplitudes and smaller field sizes.
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Affiliation(s)
- Vanida Poolnapol
- Medical Physics Program, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Taweap Sanghangthum
- Medical Physics Program, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand,Address for correspondence: Dr. Taweap Sanghangthum, Department of Radiology, Division of Radiation Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. E-mail:
| | - Mintra Keawsamur
- Division of Radiation Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Effects of flattening filter (FF) and flattening filter-free (FFF) beams on small-field and large-field dose distribution using the VMAT treatment plan. POLISH JOURNAL OF MEDICAL PHYSICS AND ENGINEERING 2021. [DOI: 10.2478/pjmpe-2021-0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Abstract
Introduction: The aim of the study was to evaluate the influence of flattening filter (FF) and flattening filter-free (FFF) beams on small-field and large-field dose distribution using the VMAT treatment plan.
Material and methods: Dose distribution calculations were performed for the VMAT technique in two locations: the larynx (small irradiation field; average 30.1 cm2) and gynecology (large irradiation field; average 173.1 cm2) using X-6MV flattening filter (FF) and flattening filter-free (FFF) beams. The following values were compared: the number of monitor units, minimum doses, average doses in PTV and maximum average doses in OaR (spinal cord – in larynx radiotherapy, bladder and rectum - in gynecological radiotherapy) and RPI (Radiation Planning Index) coefficient.
Results and Discussion: The performed statistical tests indicate that there is a significant difference (p <0.05) between the number of monitor units in the irradiation of large (gynecological) fields between the FF and FFF beams. The dose distributions show no statistically significant differences between the flattening filter and flattening-free filter beams (regardless of the field size).
Conclusions: Due to the smaller number of monitor units, it is recommended to use flattening filter beams (FF) for large-field radiotherapy.
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Hurmuz P, Cengiz M, Esen CSB, Yedekci Y, Yildiz Z, Ozyigit G, Zorlu F, Akyol F. Factors affecting post-treatment radiation-induced lung disease in patients receiving stereotactic body radiotherapy to lung. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2021; 60:87-92. [PMID: 33099668 DOI: 10.1007/s00411-020-00878-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/12/2020] [Indexed: 06/11/2023]
Abstract
The aim of the study is to investigate factors that may cause radiation-induced lung disease (RILD) in patients undergoing stereotactic body radiotherapy (SBRT) for lung tumors. Medical records of patients treated between May 2018 and June 2019 with SBRT were retrospectively evaluated. All patients should have a diagnosis of either primary non-small cell lung cancer (NSCLC) or less than three metastases to lung from another primary. The median treatment dose was 50 Gy in 4-5 fractions. Tumor response and RILD were evaluated in thoracic computer tomography (CT) using RECIST criteria. 82 patients with 97 lung lesions were treated. The median age was 68 years (IQR = 62-76). With a median follow-up of 7.2 months (3-18 months), three patients had grade 3 radiation pneumonitis (RP). RILD was observed in 52% of cases. Patients who had RILD had a higher risk of symptomatic RP (p = 0.007). In multivariate analyses older age, previous lung radiotherapy history, and median planning treatment volume (PTV) D95 value of ≥ 48 Gy were associated with RILD. Local recurrence (LR) was observed in 5.1% of cases. There was no difference in overall survival and LR with the presence of RILD. Older age, previous lung radiotherapy history, and median PTV D95 value of ≥ 48 Gy seems to be associated with post-SBRT RILD.
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Affiliation(s)
- Pervin Hurmuz
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey.
| | - Mustafa Cengiz
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey
| | | | - Yagiz Yedekci
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey
| | - Zehra Yildiz
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey
| | - Gokhan Ozyigit
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey
| | - Faruk Zorlu
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey
| | - Fadil Akyol
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey
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Aoki S, Yamashita H, Takahashi W, Nawa K, Ota T, Imae T, Ozaki S, Nozawa Y, Nakajima J, Sato M, Anraku M, Nitadori J, Karasaki T, Abe O, Nakagawa K. Salvage stereotactic body radiotherapy for post-operative oligo-recurrence of non-small cell lung cancer: A single-institution analysis of 59 patients. Oncol Lett 2020; 19:2695-2704. [PMID: 32218820 PMCID: PMC7068670 DOI: 10.3892/ol.2020.11407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022] Open
Abstract
A standard treatment for patients with early-stage non-small cell lung cancer (NSCLC) who undergo surgery, and subsequently develop local failure or intrathoracic oligo-recurrence, has not yet been established. The present study aimed to assess the feasibility of stereotactic body radiotherapy (SBRT) for this subgroup of patients. Consequently, a retrospective analysis was conducted of patients with NSCLC recurrence who were treated with SBRT, and previously underwent curative surgical resection between October 2011 and October 2016. Post-SBRT survival [overall survival (OS); progression-free survival (PFS); and local control (LC)] and toxicity were analyzed. Prognostic factors for OS were identified using univariate and multivariate analysis. A total of 52 patients and 59 tumors were analyzed. The median follow-up time was 25 months (35 months for surviving patients), and median OS following salvage SBRT was 32 months. The 1- and 3-year OS rates were 84.4 and 67.8%, respectively. 1- and 3-year PFS rates were 80.8 and 58.7%, respectively. Only 4 patients (7.7%) developed local failure. Median LC was 71 months and 1- and 3-year LC rate were 97.9 and 94.9%, respectively. A total of 4 patients experienced grade 3 or higher adverse events (AEs) and two experienced grade 5 AEs (pneumonitis and hemoptysis). Central tumor location and the possibility of re-operation were independent prognostic factors for OS. The present study indicated that post-operative salvage SBRT is a promising therapeutic option for patients with NSCLC with locoregional or intrathoracic oligo-recurrence. We regard toxicity was also acceptable. However, further research is required on the appropriate selection of subjects, and stratification of the analysis by certain risk factors would increase the accuracy of the conclusions.
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Affiliation(s)
- Shuri Aoki
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Hideomi Yamashita
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Wataru Takahashi
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Kanabu Nawa
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Takeshi Ota
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Toshikazu Imae
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Sho Ozaki
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Yuki Nozawa
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Jun Nakajima
- Department of Thoracic Surgery, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Masaaki Sato
- Department of Thoracic Surgery, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Masaki Anraku
- Department of Thoracic Surgery, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Junichi Nitadori
- Department of Thoracic Surgery, University of Tokyo Hospital, Tokyo 113-8655, Japan.,Department of Thoracic Surgery, Tokyo Metropolitan Geriatric Hospital, Tokyo 173-0015, Japan
| | - Takahiro Karasaki
- Department of Thoracic Surgery, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Osamu Abe
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Keiichi Nakagawa
- Department of Radiology, University of Tokyo Hospital, Tokyo 113-8655, Japan
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