The use of photon beams of a flattening filter-free linear accelerator for hypofractionated volumetric modulated arc therapy in localized prostate cancer

To evaluate the potential usage of flattening filter-free (FFF) photon beams in the treatment of prostate cancer.Volumetric-modulated arc therapy (VMAT) treatment planning was performed for 7 patients using TrueBeam(®) linear accelerator and photon beams with (X6, X10) and without (X6FFF, X10FFF) flattening filter. Prescribed dose was 19 × 3 Gy = 57 Gy. One or two 360° arcs with dose rate of 600 MU/min for flattened beams, and 1,200 MU/min for FFF beams were used.No difference was detected between the four beams in PTV coverage, conformity, and homogeneity. Mean body dose and body volume receiving 50% of the prescribed dose decreased with increasing mean energy (r(2) = 0.8275, p0.01). X6FFF delivered 3.6% more dose compared with the X6 (p0.01). X10FFF delivered 3.0% (p0.01), and the X10 5.8% (p 0.01) less mean body dose compared with X6. There was a significant increase in the mean dose to the rectum for the X10 compared with X6 (2.6%, p0.01). Mean dose to the bladder increased by 1.3% for X6FFF and decreased by 2.3% for X10FFF. Using a single arc and FFF, treatment time was reduced by 35% (2 SD = 10%).FFF beams resulted in dose distributions similar to flattened beams. X10FFF beam provided the best solution, sparing rectum and bladder and minimizing whole-body dose. FFF beams lead to a time efficient treatment delivery, particularly when combined with hypofractionated VMAT.