Research Article|Articles in Press

Delivery of a VMAT technique with flattening filter (FF) and flattening filter free (FFF) mode for whole breast irradiation with five fractions (FAST-Forward trial)


      To investigate the feasibility of volumetric modulated arc therapy (VMAT) delivery for whole breast irradiation with a 5-fraction regimen according to the FAST-Forward trial. Recently, we treated 10 patients with carcinoma of the left breast after breast conserving surgery. The dose prescription to the PTV was 26 Gy in 5 fractions. Treatment plans were produced using a VMAT technique with the Eclipse treatment planning system for 6 MV flattening filter (FF) and FF free (FFF) beams. Dose volume histograms (DVHs) for the PTV and the organs at risk (OARs), the ipsilateral lung and heart, were compared with the dose constraints specified in the FAST-Forward trial (PTV, D95 > 95%, D5 < 105%, D2 < 107% and Dmax < 110%; ipsilateral lung, D15 < 8Gy; Heart, D30 < 1.5Gy and D5 < 7Gy). Furthermore, conformity index (CI), homogeneity index (HI) and dose to the heart, contralateral lung, contralateral breast, and left anterior descending artery (LAD), were also assessed. Mean ± SD D95(%), D5(%), D2(%), and Dmax (%) for PTV were 97.75 ± 1.12, 105.2 ± 0.82, 105.90 ± 0.89, 109.36 ± 1.00 (FF) and 96.46 ± 0.75, 103.97 ± 0.97, 104.70 ± 1.09, 108.58 ± 1.33 (FFF) respectively. The mean ± SD CI was 1.07 ± 0.05 (FF), 1.048 ± 0.06 (FFF) and HI was 0.11 ± 0.02 (FF), 0.10 ± 0.02 (FFF). Dose constraints for OARs were met for both treatment techniques. However, D15 (Gy) for ipsilateral lung was 3.0% lower with FFF beams. In contrast, D5 (Gy) for heart was 9.0% higher with FFF beams. The dose difference between FF and FFF beams for other OARs such as contralateral lung-D10 (Gy) contralateral breast-D5 (Gy) and LAD was up to 6.0%. Both FF and FFF methods met the acceptable criteria. However, the treatment plans with FFF mode were more conformal and provided greater target homogeneity.


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        • Hyuna S
        • Jacques F
        • Rebecca LS
        Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
        CA Cancer J. Clin. 2021; 71: 209-249
        • Ragaz J
        • Olivotto I.A.
        • Spinelli J.J.
        • Burnt A.M.
        • Haviland J.S.
        • Wheatley D.A.
        Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial.
        J. Natl. Cancer Inst. 2005; 97: 116-126
        • Rastogi K
        • Sharma S
        • Gupta S
        • et al.
        Dosimetric comparison of IMRT versus 3DCRT for post-mastectomy chest wall irradiation.
        Radiat. Oncol. J. 2018; 36: 71-78
        • Owen J.R.
        • Ashton A.
        • Bliss J.M.
        • et al.
        Effect of radiotherapy fraction size on tumour control in patients with early-stage breast cancer after local tumour excision: long-term results of a randomised trial.
        Lancet Oncol. 2006; 7: 467-471
        • Bentzen S.M.
        • Agrawal R.K.
        • Aird E.G.
        • et al.
        The UK Standardisation of Breast Radiotherapy (START) trial A of radiotherapy hypofractionation for treatment of early breast cancer: A randomized trial.
        Lancet Oncol. 2008; 9: 331-341
        • Wang S.L.
        • Fang H
        • Song Y.W.
        • et al.
        Hypo-fractionated versus conventional fractionatedpostmastectomy radiotherapy for patients with high-risk breast cancer: A randomized, non-inferiority, open-label, phase 3 trial.
        Lancet Oncol. 2019; 20: 352-360
        • Whelan T.J.
        • Pignol J.P.
        • Levine M.N.
        • et al.
        Long-term results of hypo-fractionated radiation therapy for breast cancer.
        N. Engl. J. Med. 2010; 362: 513-520
        • Haviland J.S.
        • Owen J.R.
        • Dewar J.A.
        • et al.
        The UK Standardization of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomized controlled trials.
        Lancet Oncol. 2013; 14: 1086-1094
        • Burnt A.M.
        • Haviland J.S.
        • Wheatley D.A.
        Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects results from a multicentre, non-inferiority, randomised, phase 3 trial.
        Lancet. 2020; 395: 1613-1626
        • Hurkmans C.W.
        • Cho B.C.J.
        • Damen E.
        • et al.
        Reduction of cardiac and lung complication probabilities after breast irradiation using conformal radiotherapy with or without intensity modulation.
        Radiother. Oncol. 2002; 62: 163-171
        • Tsuchiya K.
        • Kinoshita R.
        • Shimizu S.
        • et al.
        Dosimetric comparison between intensity-modulated radiotherapy and standard wedged tangential technique for whole-breast radiotherapy in Asian women with relatively small breast volumes.
        Radiol. Phys. Technol. 2014; 7: 67-72
        • Dogan N.
        • Cuttino L.
        • Lloyd R.
        • et al.
        Optimized dose coverage of regional lymph nodes in breast cancer: the role of intensity-modulated radiotherapy.
        Int. J. Radiat. Oncol. Biol. Phys. 2007; 68: 1238-1250
        • Johansen S.
        • Cozzi L.
        • Olsen D.R.
        A planning comparison of dose patterns in organs at risk and predicted risk for radiation induced malignancy in the contralateral breast following radiation therapy of primary breast using conventional, IMRT and volumetric modulated arc treatment technique.
        Acta. Oncol. 2009; 48: 495-503
        • Petrova D
        Snezana Smickovska and Emilijalazarevska. Conformity index and homogeneity index of the postoperative whole breast radiotherapy.
        Open Access Maced. J. Med. Sci. 2017; 5: 736-739
        • The ICRU Report:
        prescribing, recording and reporting photon-beam intensity-modulated radiation therapy (IMRT).
        J. ICRU. 2010; 10 (Oxford University Press)
        • Fiorentino A.
        • Ruggieri R.
        • Giaj-Levra N.
        • et al.
        Three dimensional conformal versus intensity modulated radiotherapy in breast cancer treatment: is necessary a medical reversal?.
        Radiol. Med. (Torino). 2017; 122: 146-153
        • Pierce L.J.
        • Feng M.
        • Griffith K.A.
        • et al.
        Michigan radiation oncology quality consortium. recent time trends and predictors of heart dose from breast radiation therapy in a large quality consortium of radiation oncology practices.
        Int. J. Radiat. Oncol. Biol. Phys. 2017; 99: 1154-1161
        • Li J.B.
        • Wang J.G.
        • Lu J.
        • et al.
        Influence of active breathing control on the dose distribution in the target of forward whole-breast intensity-modulated radiotherapy after breast conserving surgery.
        Chin. Clin. Oncol. 2009; 31: 617-621
        • Ma C
        • Zhang W
        • Lu J
        • et al.
        Dosimetric comparison and evaluation of three radiotherapy techniques for use after modified radical mastectomy for locally advanced leftsided breast cancer.
        Sci. Rep. 2015; 5: 12274
        • Majumdar SKD
        • Amritt A
        • Dhar SS
        • et al.
        A dosimetric study comparing 3D-CRT vs. IMRTvs. VMAT in left-sided breast cancer patients after mastectomy at a tertiary care centre in eastern India.
        Cureus. 2022; 14: 1-13
        • Sudha S.P.
        • Seenisamy R.
        • Bharadhwaj K.
        Comparison of dosimetric parameters of volumetric modulated arc therapy and three-dimensional conformal radiotherapy in postmastectomy patients with carcinoma breast.
        J. Cancer Res. Ther. 2018; 14: 1005-1009
        • Viren T
        • Heikkilä J
        • Myllyoja K
        • et al.
        Tangential volumetric modulated arc therapy technique for left-sided breast cancer radiotherapy.
        Radiat. Oncol. 2015; 10: 1-8