Feasibility study of using flattening-filter-free photon beams to deliver conventional flat beams

Various dosimetric benefits such as increased dose rate, and reduced leakage and out of field dose have led to the growth of flattening-filter-free (FFF) technology in the clinic. In this study, we concentrate on investigating the feasibility of using FFF beams to deliver conventional flat beams, since completely getting rid of the flattening-filter module from the gantry head can not only simplify the gantry design but also decrease the workload on machine maintenance and quality assurance. Two intensity modulated radiotherapy techniques, step-and-shoot (S&S) and sliding window (SW), were used to generate flat beam profiles for 6 regular-shaped beams and 3 clinical beams while operating in FFF mode. The inverse plans were generated based on uniform dose optimization. Degree of flatness, MU efficiency, and beam delivery time for both methods were assessed. S&S technique is able to achieve a degree of flatness less than 2.5% for most field configurations. While SW technique was able to generate relatively flat beams for field sizes less than 18 × 18 cm². For all field configurations, S&S beams resulted in a longer delivery time compared to reference flat beams and SW beams. For field sizes less than 18 × 18 cm², SW modulated FFF beams resulted in a faster delivery time compared to reference flat beams. The ability to deliver conventional flat beams is not absent when operating in FFF mode. Utilizing beam modulation, FFF mode can achieve reasonable flat profiles and comparable efficiency to conventional flat beams. The ability to deliver most clinical treatments from the same treatment unit will allow for less quality assurance as well as maintenance, and completely eliminate the need for the flattening filter on modern linacs.