DOI:10.22034/APJCP.2017.18.11.

2965
Dosimetric Validation of VMAT Using AAPM TG-119 Benchmark Plans for FFF Photon Beam

RESEARCH ARTICLE

Dosimetric Validation of Volumetric Modulated Arc Therapy

(VMAT) Using AAPM TG-119 Benchmark Plans in an
Upgraded CLINAC 2100CD for Flattening Filter Free (FFF)
Photon Beams
Ashokkumar Sangaiah1,2*, K M Ganesh1,3, K Ramalingam1,2, K Karthikeyan1,2,
N Jagadheeskumar2
Abstract
Background: Recently we have upgraded our Varian Clinac 2100CD with a 6MV FFF beam, this upgrade being
the first of its kind in our country. Even though the dosimetric characteristics of FFF beams have been reported both in
experimental and Monte Carlo studies, application in planning and delivery is complex. The aim of this study was to
validate the commissioning of upgraded FFF beams dosimetrically using AAPM TG-119 bench mark plans for VMAT
and to make a comparison with IMRT plans for both flattened filtered and FFF beams. Materials and Methods: AAPM
TG-119 proposes a set of test clinical cases for testing the accuracy of IMRT planning and delivery systems. For these
clinical cases we generated four treatment plans using IMRT FF, IMRT FFF, VMAT FF and VMAT FFF on a Varian
Clinac 2100CD machine equipped with a millennium 120 MLC in Eclipse treatment planning system. Dose prescription
and planning objectives were set according to the TG-119 goals and plans were scored based on planning objectives.
Plans were compared using dose coverage, the conformity index and the homogeneity index. Point doses were measured
at points recommended by TG-119 using a CC13 ion chamber. Planar dosimetry was accomplished using Imatrix and
gamma evaluation was conducted using Omnipro IMRT software. Results: Dose distributions of FFF beam based
plans were comparable to FF plans for both IMRT and VMAT. Our planning results matched TG-119 planning results.
Measured point doses were within ±2% of planned doses and planar dosimetry gamma values were <1 for >95% of
data points for all plans. Conclusion: We found a reduction of 40% treatment time for FFF against FF beams for sliding
window IMRT. Upgraded FFF beams were in good agreement with TG-119 benchmark plans and goals.

Keywords: FF- FFF- VMAT- TG-119- patient specific QA

Asian Pac J Cancer Prev, 18 (11), 2965-2970

Introduction optimization employs an aperture-based method that

incorporates MLC leaf positions and Monitor Unit (MU)
Volumetric-modulated arc therapy (VMAT) has shown weights as optimization parameters (Otto, 2008).
a promising delivery method resulting in plan quality The Flattening Filter Free beam (FFF) has been
of equal or better than that of IMRT for several sites. It introduced to increase dose rate and reduce leaf
has gained widespread adoption in the recent years by transmission, head scatter, and leakage radiation. The
treating various sites, including prostate, spine, head and treatment time can be reduced significantly for stereotactic
neck. The dynamic features of VMAT and corresponding body radiation therapy (SBRT) delivery. A sharper
optimization constraints are significantly different from penumbra can also be generated from FFF beams. There
the dynamic MLC delivery technique in IMRT (Eugenio is a noticeable dose reduc¬tion outside the field in FFF
et al., 2009; Wiehle et al., 2011; Subramanian et al., 2012). beams compared to Flattening Filtered (FF) beams, which
VMAT uses dynamic MLCs, variable dose rate and can improve the target conformity and sharper dose fall-off
gantry speed to generate quality dose distributions in a to limit radiation dose to distant organs (Thirumalai et al.,
single optimized arc around the patient. VMAT can now 2015; Hansen et al., 1972).
continuously modulate the dose to the entire tumor volume Our Varian Clinac 2100CD linear accelerator
while sparing of normal and healthy tissue. VMAT dose was upgraded with 6MV FFF beam which had only

1
Research and Development center, Bharathiar University, Coimbatore-641046, 2Department of Radiation Oncology, Yashoda
Hospitals,Secunderabad-500003, 3Department of Medical Physics, Kidwai Memorial Institute of Oncology, Bengaluru-560030,
India. *For Correspondence: [email protected]

Asian Pacific Journal of Cancer Prevention, Vol 18 2965

Ashokkumar Sangaiah et al

conventional 6MV FF and 15MV FF beam before. This (0°, 40°, 80°, 120°, 160°, 320°, 280°, 240° and 200°) for
upgrade was first of its kind in our country. This 6 MV IMRT and two complimentary full arcs were used for
FFF beam has a maximum dose rate of 1400MU/min (140, VMAT. For all VMAT plans we maintained the collimator
280, 420, 560, 700, 840, 980, 1120, 1260, 1400 MU/min) angle at ± 10° while for IMRT plans 0° collimator angle
with the multiples of 140. Even though the dosimetric was applied throughout.
characteristics of FFF beam have been reported both in All IMRT plan optimizations were done with dose
experimental and Monte Carlo studies, the applications volume optimization (DVO) algorithm and for VMAT
of FFF beam in the planning and delivery is complicated plan optimizations were done using progressive resolution
and it requires validation in preclinical situation. optimizer (PRO-III) algorithm. Dose calculations for
In year 2009 AAPM (American Association of all plans were performed using analytical anisotropic
Physicists in Medicine) Task Group 119 (TG119) has algorithm (AAA) with a dose calculation grid size of 2.5
developed a set of test cases to assess the overall accuracy mm and heterogeneity corrections were applied. All plans
of planning and delivery of IMRT treatments to produce were normalized to an isodose line that ensured coverage
quantitative confidence limits as baseline expectation of the volume to meet TG 119 requirements. Dose
values for IMRT commissioning (Ezzell et al., 2009). prescription and planning objectives were set according
Dinesh Kumar et al., (2012) used TG 119 as a metric to to the TG-119 goals and planning objectives as shown
determine the capability of VMAT plan delivery with in Table 1. Treatment plans were compared using dose
6MV FF beam. coverage, conformity index (CI) for reference dose (D95),
Aim of this study is to validate the commissioning of homogeneity index (HID5–D95) and treatment time.
upgraded 6MV FFF beam dosimetrically using AAPM For all the IMRT and VMAT plans verification plans
TG-119 benchmark plans for VMAT and to compare with were created to measure point dose and planar dose. These
IMRT plans for both FF and FFF beams. measurements were done in a plane recommended by
TG-119. Point doses were measured using ion chamber
Materials and Methods CC13. Planar Dosimetry was done using I matrix with
Multicube phantom (iba dosimetry, Germany) and gamma
Computed tomography (CT) datasets of the test cases evaluation was done using Omnipro IMRT software (Xin
were downloaded directly from the AAPM website (www. et al., 2012).
aapm.org) and imported into our treatment planning This study has been bifurcated for convenience. The
system. Figure 1 shows the test structures of these first section compares the plan parameters achieved with
CT’s superimposed upon a set of water-equivalent slab TG-119 results and in the second section TG-119 point
phantom. TG 119 problem set consists of four structure dose and planar dose, measurement results were compared.
sets namely test prostate, head-and-neck (H and N),
C-shaped and Multi Target. Prostate structure set consists Results
of prostate GTV, prostate PTV, rectum and bladder.
One-third of rectum is overlapped with prostate PTV. In A. Plan comparison
test head and neck case with PTV, we have OARs left (LT) Figure 2(a) shows the prostate plan results where PTV
and right (RT) parotids and spinal cord. There is 1.5cm D95 and D5 of IMRT and VMAT plans with both 6FF
gap between spinal cord and PTV. The C-shape structure and FFF are comparable to TG 119 plans, where the dose
set consists of C-shape PTV with 1.5cm inner and 3.7cm prescription is 75.6 Gy to D95. All criteria were achieved
outer radius. OAR core is a cylindrical structure of 1cm or exceed the requirements of TG 119. Figure 3 shows
radius and with a gap of 0.5 cm between C-shape PTV
and core. Multi-target structure set has three cylindrical
structures of 4cm diameter and 4cm length stacked along
the coronal axis. Full description of all the structure sets
is available, with dimensions, and goals in AAPM TG 119
report. AAPM TG 119 defines the beam arrangement,
IMRT goals, and methods for analyzing the dosimetric
results.
For these test cases, we generated four treatment
plans (namely IMRT FF, IMRT FFF, VMAT FF and
VMAT FFF) on Varian Clinac 2100CD machine
equipped with millennium 120 MLC (Varian Medical
Systems, Palo Alto, CA) in Eclipse treatment planning
system version 11.0. The IMRT plan was done using
static 7-9 dynamic Multi-Leaf Collimator (dMLC) and
a VMAT plan utilizing one- or two-arc. For prostate
and Multi Target cases, seven static gantry angles 50°
apart (0°, 50°, 100°, 150°, 310°, 260° and 210°) and
one full arc (175° to 185°) were chosen for IMRT and
VMAT plans respectively. For head-and-neck and
C-shaped tests, nine static gantry angles 40° apart Figure 1. AAPM TG-119 Test Structure Set
2966 Asian Pacific Journal of Cancer Prevention, Vol 18
 DOI:10.22034/APJCP.2017.18.11.2965
Dosimetric Validation of VMAT Using AAPM TG-119 Benchmark Plans for FFF Photon Beam
Table 1. AAPM TG 119 Goals and Results with Standard Deviation (SD) for Test Cases
Test Case Planning Parameter Plan goal Mean Standard Deviation Coefficient of variation
(cGy) (cGy) (cGy)
Prostate Prostate D95 > 7,560 7,566 21 0.003
Prostate D5 < 8,300 8,143 156 0.019
Rectum D30 < 7,000 6,536 297 0.045
Rectum D10 < 7,500 7,303 150 0.02
Bladder D30 < 7,000 4,394 878 0.2
Bladder D10 < 7,500 6,269 815 0.13
Head and Neck PTV D90 5,000 5,028 58 0.013
PTV D99 > 4,650 4,704 52 0.011
PTV D20 < 5,500 5,299 93 0.018
Cord maximum < 4,000 3,741 250 0.067
Parotid < 2,000 1,798 184 0.102
C-shape PTV D95 < 5,000 5,011 16.5 0.003
PTV D10 < 5,500 5,702 220 0.039
Core 1,000 1,630 307 0.188
Multi Target Central target D99 > 5,000 4,955 162 0.033
Central target D10 < 5,300 5,455 173 0.032
Superior target D99 > 2,500 2,516 85 0.034
Superior target D10 < 3,500 3,412 304 0.089
Inferior target D99 > 1,250 1,407 185 0.132
Inferior target D10 < 2,500 2,418 272 0.112

prostate case IMRT and VMAT plan DVHs for PTV, constraint for parotid is D50 less than 20 Gy, IMRT
rectum and bladder. For prostate case IMRT and VMAT plans with both 6 FF and FFF achieved less dose to both
plans have comparable DVH. the parotids compared to the VMAT plans as shown in
Figure 4 shows Head and Neck case IMRT and Figure 2(b).
VMAT DVHs for PTV, cord, right and left parotids. The Figure 2(c) shows C-shaped plan results for IMRT and
maximum cord doses for IMRT and VMAT for 6FF plans VMAT plans for both 6FF and 6FFF. The target and core
were 39.49 Gy and 39.30 Gy and for 6FFF were 39.89 dose goals are achieved. PTV plan prescrip¬tion is 50
Gy and 39.90 Gy respectively, but they are greater than Gy to outer target, both IMRT and VMAT plans achieved
the given constraint (< 38.50 Gy). However, AAPM TG PTV D10 very close to the planning goal of 55 Gy. All the
119 cord maximum standard deviation is 2.50 Gy and plans achieved D5 constraint of OAR core, and results are
our results are within one standard deviation. The dose comparable to TG 119 plan results. Figure 5 shows the
C-shaped plan DVHs of IMRT and VMAT plans for 6FF
and 6FFF beams the results shows core and target DVHs
are comparable.
Figure 2(d) shows for Multi Target plan results for
IMRT and VMAT plans with 6FF and 6FFF achieved

Figure 2. Results Achieved for AAPM TG-119 Test Figure 3. Prostate Plan Comparison DVH
Clinical Cases
Asian Pacific Journal of Cancer Prevention, Vol 18 2967
 Table 3. Gamma Analysis Results of Planar Dosimetry

97.57
98.06
97.09

99.19
98.63
97.39

98.75
FFF
VMAT
Figure 4. Head and Neck Plan Comparison DVH

97.65
95.15
97.78

98.17
96.02
97.84

98.88
FF
Figure 6. Multi Target Plan Comparison DVH
Figure 5. C-Shape Plan Comparison DVH

97.98
98.24

96.84

97.64

97.59
97.6

96.8
FFF
IMRT
in High Dose and Low Dose Regions

98.37
98.48
98.72

97.45
98.04
96.78

98.55
FF
Multi target

Head and

Head and
C-Shape

C-Shape
Prostate

Prostate
Neck

Neck
Test
Gamma criteria

3% DD and

5% DD and
(High dose
3mm DTA

5mm DTA
(Low dose
region)

region)
Table 2. Point Dosimetry Results in High and Low Dose Regions
High Dose Region Point Dose (Gy)

Asian Pacific Journal of Cancer Prevention, Vol 18

IMRT 6FF IMRT 6FFF VMAT 6FF VMAT 6FFF
Case Measured Planned Deviation Measured Planned Deviation Measured Planned Deviation (%) Measured Planned Deviation (%)
(%) (%)
Test Prostate 2.3 2.33 -1.29 2.34 2.31 1.3 2.28 2.31 -1.3 2.33 2.3 1.3
Test H&N 1.95 1.98 -1.52 2.45 2.41 1.66 2 2.03 -1.48 2.38 2.36 0.85
C-Shape 0.41 0.43 -4.65 0.428 0.427 0.23 0.453 0.454 -0.22 0.374 0.367 1.91
Multi Target 1.97 2.01 -1.99 1.98 2.02 -1.98 2.03 2 1.5 2.03 2 1.5
Low Dose Region Point Dose (Gy)
Ashokkumar Sangaiah et al

IMRT 6FF IMRT 6FFF VMAT 6FF VMAT 6FFF

Case Measured Planned Deviation Measured Planned Deviation Measured Planned Deviation (%) Measured Planned Deviation (%)
(%) (%)
Test Prostate 1.02 1.08 -5.56 2.34 2.31 1.3 0.83 0.85 -2.35 0.97 0.99 -2.02
Test H&N 1.38 1.39 -0.72 2.47 2.41 2.49 1.59 1.56 1.92 1.67 1.64 1.83

2968
C-Shape 2.08 2.12 -1.89 0.428 0.427 0.23 1.99 2 -0.5 2.04 1.99 2.51
 DOI:10.22034/APJCP.2017.18.11.2965
Dosimetric Validation of VMAT Using AAPM TG-119 Benchmark Plans for FFF Photon Beam

Figure 9. Treatment Time Comparison for TG-119 Test

Clinical Cases

gradient region (organ at risk region). The dose deviations

Figure 7. IMRT and VMAT Dose Distribution were within ±2 % of planned values in PTV region and
Comparison for Test Prostate, Head and Neck, C-Shape within ±5% in organ at risk region, but in case of prostate
and Multi Target when the point dose were measured at rectum region the
percentage of deviation is up to 5.39% but the absolute
dose deviation is 0.6 Gy only.

B.2 Planar dose Measurements

Planar dose measurements were measured in a plane
recommended by TG-119. The gamma analysis work
space of C-shape target is shown in the figure 8. In high
dose and low gradient region, the passing criteria is 3%
dose difference (DD) and 3mm distance to agreement
(DTA) is accepted and in low dose and high gradient
region the criteria is 5% DD and 5mm DTA were accepted
(Palta et al., 2008) and the gamma analysis results are
tabulated in table 3. All gamma evaluation results show
gamma less than one for more than 97% data points with
the given criteria.

B.3 Treatment Time comparison

Figure 8. Planned Axial Dose Distribution (a) at central The beam ‘ON’ time comparison for 6 MV FF and
core level (i.e., low-dose region) of 6X FFF C-shape plan FFF were done for TG-119 test clinical cases. The beam
using VMAT technique; (b) Measured in detractor array ‘ON’ time was defined as the time elapsed between the
at the same level; (c) the corresponding X and Y profiles beam ‘ON’ of the first Arc/Field and the beam ‘OFF’ of the
for planned and delivered doses. (d) Gamma analysis
results with 3%/3 mm criteria (98.63% of pixels passed) last Arc/Field of the treatment. Study found that Sliding
window IMRT with FFF beam shows significant reduction
in treatment time as compare to conventional FF beam
the planning goals. When compared to the benchmark the as shown in figure 10. However, in case of VMAT,
TG 119 results, our IMRT and VMAT plans have more the reduction in treatment time was not significant as the
homogenous coverage to superior and inferior targets and dose per fraction is low and the gantry speed cannot be
similar results for the center target. Figure 6 shows IMRT increased beyond 4.8º/ sec.
and VMAT dose volume histograms of superior, inferior, In conclusion, upgraded FFF beams were in good
and center target are comparable. agreement with TG-119 Bench mark plans and goals. It
Figure 7 shows frontal plane VMAT dose distribution is helpful to gain confidence in new modalities like FFF
comparison between 6FF and 6FFF for Test prostate, head based VMAT and to test its capabilities at preclinical
and neck, C-shape and Multi Target. All the plans dose implementation stage. Interestingly the study reveals that
coverage is comparable to each other. The conformity the sliding window IMRT with 6 MV FFF beam shows
index ranged 1.006 to 1.182 and the homogeneity index 40% reduction in the treatment time as compared to FF
ranged from 1.03 to 1.078. beam. We require multi-institutional and multiple-vendor
study for true benchmarking of VMAT programs, as done
Discussion in TG 119.

B. TG-119 measurements Statement conflict of Interest

B.1. Point measurement results Authors have no conflict of Interest.
Table 2 shows the point dose results in high dose and
low gradient region (PTV region) and low dose and high
Asian Pacific Journal of Cancer Prevention, Vol 18 2969
Ashokkumar Sangaiah et al

References
Dinesh Kumar M, Ravindra Y, Linda H, Hsiang-Chi K, Dennis
M (2012). Application of AAPM TG 119 to volumetric arc
therapy (VMAT). J Appl Clin Med Phys, 13, 108-16.
Eugenio V, Alessandro C, Giorgia N, et al (2009). Volumetric
modulated arc radiotherapy for carcinomas of the
oro-pharynx, hypo-pharynx and larynx: A treatment planning
comparison with fixed field IMRT. Radiother Oncol, 92,
111-17.
Ezzell GA, Burmeister JW, Dogan N, et al (2009). IMRT
commissioning: multiple institution planning and dosimetry
comparisons, a report from AAPM Task Group 119. Med
Phys, 36, 5359–73.
Hansen HH, Connor WG, Doppke K, Boone MML (1972). A new
field flattening filter for the clinac-4. Radiology, 103, 443-6.
Jatinder R, Palta, Liu C, Li JG (2008). Quality assurance of
intensity-modulated radiation therapy. Int J Radiat Oncol
Biol Phys, 71, 108-12.
Otto K (2008). Volumetric modulated arc therapy: IMRT in a
single gantry arc. Med Phys, 35, 310–7.
Subramanian S, Srinivas C, Ramalingam K, et al (2012).
Volumetric modulated arc-based hypofractionated
stereotactic radiotherapy for the treatment of selected
intracranial arteriovenous malformations, Dosimetric report
and early clinical experience. Int J Radiat Oncol Bio Phys,
82, 1278-84.
Shanmugam TS, Chandrasekaran AR, Gandhi A, Murugesan K,
Sai S (2015). Planning and dosimetric study of volumetric
modulated arc based hypofractionated stereotactic
radiotherapy for acoustic schwannoma - 6MV flattening filter
free photon beam. Asian Pac J Cancer Prev, 16, 5019-23.
Wiehle R, Knippen S, Grosu AL, Bruggmoser G, Hodapp N
(2011) VMAT and step-and-shoot IMRT in head and neck
cancer: a comparative plan analysis. Strahlenther Onkol,
187, 820-5.
Xin Y, Wang JY, Li L, et al (2012). Dosimetric verification
for primary focal hyper metabolism of nasopharyngeal
carcinoma patients treated with dynamic intensity-modulated
radiation therapy. Asian Pac J Cancer Prev, 13, 985-9.

2970 Asian Pacific Journal of Cancer Prevention, Vol 18