Hsu et al.

Radiation Oncology (2017) 12:155

DOI 10.1186/s13014-017-0890-0

RESEARCH Open Access

Dosimetric comparison of different

treatment modalities for stereotactic
radiotherapy
Shih-Ming Hsu1,2,3*, Yuan-Chun Lai1,4,5, Chien-Chung Jeng4 and Chia-Ying Tseng1,2

Abstract
Background: The modalities for performing stereotactic radiotherapy (SRT) on the brain include the cone-based
linear accelerator (linac), the flattening filter-free (FFF) volumetric modulated arc therapy (VMAT) linac, and
tomotherapy. In this study, the cone-based linac, FFF-VMAT linac, and tomotherapy modalities were evaluated
by measuring the differences in doses delivered during brain SRT and experimentally assessing the accuracy
of the output radiation doses through clinical measurements.
Methods: We employed a homemade acrylic dosimetry phantom representing the head, within which a
thermoluminescent dosimeter (TLD) and radiochromic EBT3 film were installed. Using the conformity/gradient
index (CGI) and Paddick methods, the quality of the doses delivered by the various SRT modalities was
evaluated. The quality indicators included the uniformity, conformity, and gradient indices. TLDs and EBT3
films were used to experimentally assess the accuracy of the SRT dose output.
Results: The dose homogeneity indices of all the treatment modalities were lower than 1.25. The cone-based linac
had the best conformity for all tumors, regardless of the tumor location and size, followed by the FFF-VMAT linac;
tomography was the worst-performing treatment modality in this regard. The cone-based linac had the best gradient,
regardless of the tumor location and size, whereas the FFF-VMAT linac had a better gradient than tomotherapy for a
large tumor diameter (28 mm). The TLD and EBT3 measurements of the dose at the center of tumors indicated that
the average difference between the measurements and the calculated dose was generally less than 4%. When the 3%
3-mm gamma passing rate metric was used, the average passing rates of all three treatment modalities exceeded 98%.
Conclusions: Regarding the dose, the cone-based linac had the best conformity and steepest dose gradient for
tumors of different sizes and distances from the brainstem. The results of this study suggest that SRT should be
performed using the cone-based linac on tumors that require treatment plans with a steep dose gradient, even
as the tumor is slightly irregular, we should also consider using a high dose gradient of the cone base to treat
and protect the normal tissue. If normal tissues require special protection exist at positions that are superior or
inferior to the tumor, we can consider using tomotherapy or Cone base with couch at 0° for treatment.
Keywords: Linac, Stereotactic radiotherapy, Tomotherapy, Treatment planning systems, VMAT

* Correspondence: [email protected]
1
Medical Physics and Radiation Measurements Laboratory, National
Yang-Ming University, Taipei, Taiwan, ROC
2
Department of Biomedical Imaging and Radiological Sciences, National
Yang-Ming University, No. 155, Sec. 2, Li-Nong St., Beitou District, Taipei 112,
Taiwan, ROC
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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Hsu et al. Radiation Oncology (2017) 12:155 Page 2 of 11

Background USA) were installed within the coronal slices to meas-

Stereotactic radiosurgery (SRS) can be used to treat ar- ure the distribution of the radiation doses. In the region
teriovenous malformation, glioblastoma multiforme, and where the tumor was located the slices were 2 mm
various metastasized tumors in the brain. Because lesions thick; the thickness of the remaining slices was 5 mm,
that are treated using SRS tend to be very small, and the as shown in Fig. 1.
method in which the doses are delivered differs from the
traditional multi-fractionated dose-delivery mode, the re- Treatment planning
quired radiation in SRS is usually delivered in a single CT (LightSpeed GE, USA) was applied to obtain images
dose. In stereotactic radiotherapy (SRT), the required dose of the phantom, and the thickness of each CT slice was
is fractionated into multiple doses. Because each of the 1.25 mm. The images were sent to a tomotherapy treat-
doses in a single SRT or SRS treatment is extremely large, ment planning system (TomoTherapy Planning Station
a high accuracy is necessary for the treatments, as well as Hi-ART® version 4.3.2 Accuray, USA) and a Pinnacle
a very steep dose gradient, to ensure the tumor is given a treatment planning system (Pinnacle3® Version 9.8 Phi-
sufficiently high dose while the surrounding normal tis- lips, USA). The TomoTherapy system designed all the
sues are protected and left unharmed [1]. In recent years, planning related to tomotherapy, and the Pinnacle sys-
advancements in linear accelerator (linac) based technolo- tem designed all the planning for the cone-based and
gies, including developments in image-guidance systems, FFF-VMAT linacs. All necessary beam data were entered
multileaf collimators (MLCs), and volumetric-modulated into the Pinnacle system, and commission tests were
arc therapy (VMAT), have led to linac-based treatments completed for this system. A structure with a diameter
that can achieve a high accuracy, steep gradients, and a of 3 cm was placed on the CT images to simulate the lo-
high level of conformity [2–9]. cation of the brainstem. To match the size of the colli-
Traditionally, the Gamma Knife has been the primary mating cone, spherical tumors 8, 18, and 28 mm in
tool for performing brain SRS or SRT. However, the sites diameter were placed at distances of 1 and 6 mm from
without this facility instead utilize tomotherapy and the borders of the brainstem, as shown in Fig. 2. The
MLC or cone-based linac devices to perform SRT ther- use of spherical tumors is expected to exclude the effects
apy. Tomotherapy has a linac mounted on a ring gantry, of tumor shapes in order to purely assess the differences
and a binary MLC is used to adjust the dose of the in different modalities.
photon-beam irradiation in sync with the forward mo- Different treatment plans were designed by the treat-
tion of the treatment couch, resulting in a helical and ment planning systems according to the size of the tu-
tomographic form of intensity modulated radiotherapy mors. To exclude the effects of the beam angle, all the
(TomoHelical IMRT). Linear accelerators may use either cone-based linac and FFF-VMAT linac plans used the
an MLC or a cone to shape and limit the field of radi- arc-therapy method and the same beam angles, as shown
ation. Recent developments in flattening filter-free (FFF) in Fig. 3. The beam angles were as follows: counter-
high-dose models have led to a further reduction in the clockwise from 179° to 345° with a collimator angle of 0°
probability of patient movement, thus reducing the ef- and a couch angle of 0°, counter-clockwise from 210° to
fects caused by patient movement. This has enabled the 180° with a collimator angle of 10° and a couch angle of
FFF-VMAT linac treatment modality to become a viable 0°, counter-clockwise from 179° to 0° with a collimator
tool for performing SRT. angle of 330° and a couch angle of 330°, counter-
Different treatment modalities have different output clockwise from 179° to 0° with a collimator angle of 310°
dose characteristics, which may affect the radiation and a couch angle of 300°, counter-clockwise from 179°
doses received by normal tissues surrounding the tumor to 0° with a collimator angle of 260° and a couch angle
[10–12]. Therefore, the main goal of this study is to of 270°, and clockwise from 180° to 0° with a collimator
compare the SRT treatment doses of the cone-based angle of 250° and a couch angle of 60°.
linac, FFF-VMAT linac, and tomotherapy treatment mo- The accelerator used for the cone-based linac was a 6-
dalities and evaluate the differences between doses cal- MV Elekta Synergy (Sweden) photon. Cone diameters of
culated according to treatment planning systems and 10, 20, and 30 mm were used. The accelerator used for
measured radiation doses. the FFF-VMAT linac was a 6-MV FFF Elekta Axesse
(Sweden) photon beam and was used in conjunction
Methods with a 5 mm wide Elekta Agility high-speed MLC. The
Design of dosimetry phantom following parameters were used for the TomoTherapy
A homemade acrylic phantom of the head was created system (Accuray, USA): modulation factor of 3.0, field
according to computed-tomography (CT) images of pa- width of 1 cm, pitch of 0.086.
tients. EBT3 radiochromic films (Ashland, USA) and All treatment planning were planned by the same
the cubic thermoluminescent dosimeters (Thermo, planner. In all treatment plans, a dose of 600 cGy was
Hsu et al. Radiation Oncology (2017) 12:155 Page 3 of 11

Fig. 1 Homemade acrylic dosimetry phantom of the head: (a) coronal slices and fixing rods, (b) head phantom formed from all of the coronal
slices, and (c) head phantom fixed by a mask

delivered to the tumors, and the conditions were opti- treatment plan is 1; if the 80% isodose curve is selected
mized to maintain 98% dose coverage on the tumor, with as the prescription dose, then the HI becomes 1.25
the maximum tumor dose not exceeding 125% to instead.
minimize the doses incident on the brainstem and nor- The CGI is a holistic index that consists of the con-
mal brain tissue. Maximum dose constrain of brainstem formity index (CGIc) and the gradient index (CGIg) [14].
for tumor away from brainstem 1 mm and 6 mm were The CGI is defined as
limited to 500 cGy and 200 cGy, respectively and D1% of

these were limited to 150 cGy and 100 cGy, respectively. CGI ¼ CGI C þ CGI g =2 ð2Þ
Auxiliary ROIs such as “Ring” structure were also used
to decrease the dose of normal tissue during planning. The CGIc is used to describe the relationship between
The three-dimensional (3D) dose grid of the three axes the volume of the tumor and the volume covered by the
of the Pinnacle system was set to 1 mm and that of the dose. The CGIc is defined as
tomotherapy system was set to “fine”.
 
TV
Analytic indicators of dose quality CGI C ¼  100 ð3Þ
PIV
The homogeneity index (HI) [13], conformity/gradient
index (CGI), and Paddick indices were used to compare PIV is the volume covered by the 100% prescription
the quality of the treatment plans. The HI was used to dose curve, and TV is the volume of the tumor.
describe the homogeneity of the dose within the tumor. CGIc = 100 corresponds to perfect conformity of the
The HI is defined as treatment planning. .
HI ¼ MD=PD; ð1Þ The CGIg is the effective difference in radius between
the volumes covered by the 50% and 100% doses; it is
where MD is the maximum dose within the tumor, and used to evaluate the decrement of the dose in the high-
PD is the 100% prescription dose. The HI of a perfect dose region (50% and above) and is defined as follows:

Fig. 2 CT images of the homemade acrylic dosimetry phantom of the head: (a) transverse view, (b) sagittal view, (c) coronal view (Red, the simulated
brainstem; Green, tumor of 8 mm diameter and 1 mm away from brainstem; Blue, tumor of 8 mm diameter and 6 mm away from brainstem; Pink,
tumor of 18 mm diameter and 1 mm away from brainstem; Dark-green, tumor of 18 mm diameter and 6 mm away from brainstem; Yellow-green,
tumor of 28 mm diameter and 1 mm away from brainstem; Orange, tumor of 28 mm diameter and 6 mm away from brainstem.)
Hsu et al. Radiation Oncology (2017) 12:155 Page 4 of 11

represents the degree to which a tumor is covered by a

specified isodose curve. For a perfect treatment plan,
CIPaddick = 1.
The GIPaddick describes the decrement of the dose in
the high-dose region (50% and above) and is defined as

GI Paddick ¼ V 50%
ð7Þ
V 100

where V50% is the volume covered by 50% of the pre-

scription dose, and V100% is the volume covered by
100% of the prescription dose. The GIPaddick can repre-
sent the degree to which normal tissues outside the
tumor are protected. A perfect treatment plan must have
a value of the GIPaddick that approaches 1.
Fig. 3 All the beam angles used by the Pinnacle treatment
planning system
Radiation dose measurements
In this work, cubic TLD-100 dosimeters and EBT3 films
 
  were used to measure the radiation dose [17–22], with
CGI g ¼ 100− 100  Reff ;50%Rx −Reff ;Rx −0:3cm
the dose at each tumor location measured three times.
ð4Þ
Each cone-based linac and FFF-VMAT linac measure-
Reff , Rx refers to the effective radius of the volume cov- ment was accompanied by alignment using the six
ered by the 100% prescription dose curve, and Reff , 50 % Rx degree-of-freedom image-guided cone-beam CT of the
is the effective radius of the volume covered by the 50% accelerator. MVCT was used to align the tomotherapy
prescription dose curve, with Reff defined as measurements to correct for 3D position shifts and roll-
angle deviations in the rotating gantry. FILM QATM
rffiffiffiffiffiffiffi
3 3V Version 2.2 was used to evaluate the profile changes in
Reff ¼ ð5Þ the right–left (R–L) and superior–inferior (S–I) direc-
4π
tions, and gamma evaluation was used to determine the
V is the volume covered by the required dose. This differences between the calculated dose of the treatment
3 mm in distance between Reff , 50 % Rx and Reff , Rx gradient plan and the two-dimensional planar dose measured by
was obtained empirically from clinical radiosurgery plan- the EBT3 films. Because SRT treatments characteristic-
ning cases, and corresponds to the possible gradient ally require a high level of positional accuracy and a
with linac radiosurgery when using multiple noncopla- steep gradient, the 3% 3-mm and 5% 1-mm criteria were
nar arcs. As CGIg more than 100, it corresponds to less chosen as the gamma passing rate metrics for assessing
gradient than an optimum 3 mm empirically.. the differences in the planar doses.
The Paddick indices are clinically used to describe the
conformity [15] and gradient [16] of the treatment plan. Statistical analysis
The Paddick indices include the conformity index The Mann–Whitney test (Statistical Package for the So-
(CIPaddick) and the gradient index (GIPaddick). As the cial Sciences, IBM Corporation, New York, USA) was
CGIc is unable to present the degree of tumor-volume used to assess the statistical significance of the gamma
coverage for a specified prescription dose curve, the analysis results for the different techniques.
CIPaddick complements the CGIc by describing the vol-
ume covered by the prescription dose as well as the rela- Results
tionship between the tumor volume covered by the Dose-quality analysis
prescription dose and the overall volume of the tumor. The results of the cone-based linac, FFF-VMAT linac,
The CIPaddick is defined as and tomotherapy dose-quality analyses are shown in
Table 1. The average HI values of the cone-based linac,
ðTV PIV Þ2 the FFF-VMAT linac, and tomotherapy were 1.20 ± 0.03,
CIPaddick ¼ ð6Þ
TV  PIV 1.21 ± 0.03, and 1.23 ± 0.02, respectively. As it was
strictly specified that the maximum dose on the tumors
where PIV refers to the volume covered by the 100% did not exceed the 125% of the prescription dose during
prescription dose curve, TV is the tumor volume, and the creation of the treatment plans, none of the average
TVPIV is the tumor volume covered by PIV. This index HIs of the treatment plans exceeded 1.25. The lowest HI
Hsu et al. Radiation Oncology (2017) 12:155 Page 5 of 11

Table 1 HI, CGI, and Paddick indices calculated by the treatment planning system using the cone-based linac, FFF-VMAT linac, and
tomotherapy treatment modalities
Tumor 8 mm 18 mm 28 mm
Diameter
Distance 1 mm 6 mm 1 mm 6 mm 1 mm 6 mm
from
brainstem
Modality Cone- FFF- Tomo Cone- FFF- Tomo Cone- FFF- Tomo Cone- FFF- Tomo Cone- FFF- Tomo Cone- FFF- Tomo
based VMAT based VMAT based VMAT based VMAT based VMAT based VMAT
HI 1.24 1.25 1.20 1.23 1.25 1.23 1.20 1.19 1.25 1.20 1.17 1.24 1.17 1.23 1.21 1.16 1.19 1.23
CGIc 84.59 48.89 47.96 86.25 67.93 46.79 92.02 75.66 69.75 95.35 73.99 67.76 98.99 95.44 86.04 99.84 92.27 86.68
CGIg 103.25 66.45 74.39 103.15 74.30 75.96 88.43 60.53 60.61 89.33 59.71 62.68 74.02 52.79 48.02 75.26 61.62 50.49
CGI 93.92 57.67 61.18 94.71 71.11 61.38 90.23 68.10 65.18 92.34 66.85 62.22 86.50 74.11 67.03 87.55 76.95 68.58
CIPaddick 0.82 0.48 0.47 0.84 0.66 0.45 0.90 0.73 0.68 0.92 0.72 0.66 0.94 0.92 0.84 0.95 0.88 0.81
GI Paddick 4.23 10.97 9.07 4.28 10.58 8.57 3.02 4.90 4.83 3.00 4.93 4.62 2.73 3.67 4.14 2.69 3.21 3.90

(1.16) was observed when the cone-based linac was used Dose measurements
to treat 28 mm diameter tumors that were located 6 mm The dose-linearity curves of TLD and EBT3 (0–800 cGy)
from the brainstem. are shown in Fig. 4. The radiation doses at the center of
The average CGI values for the cone-based linac, the the tumors within the phantom were clinically measured
FFF-VMAT linac, and tomotherapy were 90.88 ± 3.37, and compared with the dose calculated in the treatment
69.13 ± 6.74, and 64.26 ± 3.13, respectively. In general, plan; the differences are shown in Table 2. The TLD and
the FFF-VMAT linac had higher CGI values than EBT3 dose measurements indicated that the average dif-
tomotherapy except for tumors with small distance from ferences between the output doses of the cone-based
the brainstem. The average CGIc values for the cone- linac, the FFF-VMAT linac, and tomotherapy and the cal-
based linac, the FFF-VMAT linac, and tomotherapy were culated doses of the treatment plans were generally lower
92.84 ± 6.41, 75.70 ± 17.01, and 67.50 ± 17.48, respect- than 4%. The largest observed difference was −3.68%
ively. For all distances from the brainstem and tumor di- (−4.52% to −3.27%) for the cone-based linac and was mea-
ameters, the cone-based linac exhibited the highest CGIc sured using the EBT3 film.
values, followed by the FFF-VMAT linac, and finally Figure 5 shows the dose profile measured using EBT3
tomotherapy. films for tumors locaed 1 mm from the brainstem in the
The average CGIg values for the cone-based linac, R–L and S–I directions. The results of the measurement
the FFF-VMAT linac, and tomotherapy were using the EBT3 film are generally consistent with calcu-
88.91 ± 12.78, 62.57 ± 7.23, and 62.03 ± 11.65, re- lations of the treatment plan. The average dose profile
spectively. The FFF-VMAT linac had higher CGIg widths of the 50% and 30% doses relative to the dose at
values than tomotherapy for large-diameter tumors the center of the tumor for tumors of various sizes are
(28 mm), with ratios of 52.79: 48.02 and 61.62: 50.49 shown in Fig. 6. The 30% profile widths of the FFF-
for distances of 1 and 6 mm from the brainstem, re- VMAT linac were smaller than those of tomotherapy for
spectively. The average CIPaddick for the cone-based all tumor volumes because the gantry rotated in a copla-
linac, the FFF-VMAT linac, and tomotherapy were nar fashion, synchronized with the movement of the
0.90 ± 0.05, 0.73 ± 0.16, and 0.65 ± 0.16, respectively. treatment couch, during the tomotherapy treatments to
Regardless of the tumor diameter and distance from enable irradiation of the tumor. Because the R–L direc-
the brainstem, the cone-based linac exhibited the best tion lies within the beam pathway, the distribution of
CIPaddick values, followed by the FFF-VMAT linac, low-intensity doses in the R–L direction was broadened.
and finally tomotherapy. The GIPaddick value of the The gamma passing rates of the three treatment mo-
FFF-VMAT linac for large-diameter tumors (28 mm) dalities under two different gamma passing criteria are
was better than that of tomotherapy, with ratios of shown in Fig. 7. When the 3% 3-mm criteria was used
3.67: 4.14 and 3.21: 3.90 for distances of 1 and 6 mm as the passing metric, the passing rates for the cone-
from the brainstem. However, tomotherapy had better based linac, the FFF-VMAT linac, and tomotherapy were
GIPaddick values than the FFF-VMAT linac for 99.28 ± 1.36%, 98.71 ± 1.39%, and 99.98 ± 0.18%, re-
smaller-diameter tumors (8 mm), with ratios of 9.07: spectively. Among these, tomotherapy had the highest
10.97 and 8.57: 10.58 for distances of 1 and 6 mm passing rate (p < 0.05), and there was no statistically sig-
from the brainstem, respectively. nificant difference between the passing rates for the
Hsu et al. Radiation Oncology (2017) 12:155 Page 6 of 11

Fig. 4 Dose-linearity curves for 6 MV: (a) TLD and (b) EBT3

cone-based and FFF-VMAT linacs (p = 0.235). Consider- cone-based linac, there were no significant changes for a
ing that SRT treatments characteristically require a high cone treatment at a distance difference of only 5 mm
level of positional accuracy and steep dose gradients, the distance to brainstem.
treatment modalities were also evaluated using the 5% Because the radiation field of the cone-based linac was
1-mm criteria as the passing metric. In this case, the similar to the size of the tumors, this modality yielded
passing rates for the cone-based linac, the FFF-VMAT the highest CGIc and CIPaddick. Unlike the cone-based
linac, and tomotherapy were 97.73 ± 2.42%, 93.53 ± linac, tomotherapy uses a constant jaw size, leading to a
3.82%, and 98.19 ± 2.09%, respectively. Among these, “ramp-up” effect, which causes normal tissues surround-
the FFF-VMAT linac had the lowest passing rate ing the tumor in the S–I direction to receive a higher
(p < 0.01), and there was no significant difference be- dose [23].
tween the passing rates for the cone-based linac and The use of a cone in the cone-based linac minimized
tomotherapy (p = 0.46). the dose divergence, resulting in the cone-based linac
The gamma evaluation maps of 28 mm diameter tu- having the best CGIg and GIPaddick among the three
mors located 1 mm from the brainstem using the 3% 3- treatment modalities. When the tumor volume was very
mm and 5% 1-mm criteria were analyzed, as shown in small, the jaw used in tomotherapy limited the disper-
Fig. 8. Here, changing the passing metric caused an in- sion range of the low-dose region, causing the CGIg to
crease in the failed areas in regions with steep doses at be higher than that for the FFF-VMAT linac. As the
the borders of the tumor for the cone-based and FFF- tumor volume increased, the dose on the brainstem
VMAT linac modalities. The cone-based linac and increased.
tomotherapy retained a gamma passing rate of 95% and The research of Yip et al. [12] indicated that, regard-
above, whereas the passing rate of the FFF-VMAT linac less of the conformity and gradient, the cone-based linac
decreased below 95%. performed better than tomotherapy for tumors with a
regular shape; this finding is consistent with our results.
Discussion However, Soisson et al. [24] reported that excellent levels
The result of this study show that the average HI for the of tumor conformity were achieved using tomotherapy.
cone-based linac was lower than those for the FFF- Nevertheless, we obtained a similar result with respect
VMAT linac and tomotherapy because of the radiation to the overall evaluation of the CGI. Soisson et al. did
of the cone-based linac was homogeneous. As a result of not provide a detailed comparison between the doses of
no dose-intensity control within the radiation field of the FFF-VMAT linac and tomotherapy for SRT, whereas

Table 2 Average difference in the dose at the center of tumors between the calculated doses from the treatment planning system
and the doses measured using TLD and EBT3 for the cone-based linac, the FFF-VMAT linac, and tomotherapy
Dosimeter Cone-based linac FFF-VMAT linac Tomotherapy
TLD (%) −1.38 (−4.08 to 0.81) −1.34 (−4.96 to 4.04) 1.05 (−2.10 to 3.65)
EBT3 (%) −3.68 (−4.52 to −3.27) −1.75 (−4.70 to 2.52) −1.02 (−3.72 to 0.58)
Hsu et al. Radiation Oncology (2017) 12:155 Page 7 of 11

Fig. 5 Differences of EBT3-measured and treatment plan-calculated profiles (normalized to the dose of tumor center) in the R–L and S–I directions for
tumors located 1 mm from the brainstem with diameters of (a) 8 mm, (b) 18 mm, and (c) 28 mm
Hsu et al. Radiation Oncology (2017) 12:155 Page 8 of 11

Fig. 6 Average dose profile widths of doses that are 50% and 30% of the dose at the center of the tumor, measured using EBT3 films, in the (a)
R–L direction and (b) S–I direction

we showed that, regardless of the tumor size and dis- report, a deviation of 1 mm is allowed in the rotational
tance from the brainstem, the conformity of the FFF- center of the couch and gantry of the linear accelerator
VMAT linac was always better than that of tomotherapy. used for SRS or SRT, and the repeatability of the MLC is
The FFF-VMAT linac also had a steeper gradient than required [25]. These deviations could have affected the
tomotherapy for larger tumors, whereas tomotherapy ex- gamma analysis results for regions with a steep dose gra-
hibited a steeper gradient for smaller tumors. dient. O’Connor et al. [26] reported that errors in the
It will result in the dose accumulation to the borders position of the MLC significantly affected the results of
of 18 mm and 28 mm diameter PTV located 1 mm from gamma analysis; for example, with the 3% 1-mm criteria
brainstem if we try to lower the dose of brainstem for as the gamma analysis passing metric, a 0.8 mm devi-
FFF-VMAT linac and tomotherapy with intensity modu- ation in the position of the MLC reduced the gamma
lated field. In this situation, if we take into account the passing rates of square-field rotating beams with field
tumor coverage, it may increase the dose closed to the sizes of 16 and 40 mm by 5.7% and 4.5%, respectively. In
borders of PTV. For cone-based linac without intensity the continuous delivery of VMAT, the position of MLC
modulated field, the dose in the PTV will be more uni- at each control point must match the gantry’s speed and
form and the dose of brainstem will be reduced because dose rate, and the MLC position in this continuous
of high dose gradient. According to the AAPM TG-142 process will also be affected by gravity and the speed of

Fig. 7 Gamma passing rates of the three treatment modalities under two different gamma passing criteria: Criteria 1: 3% 3-mm and Criteria 2: 5% 1-mm
Hsu et al. Radiation Oncology (2017) 12:155 Page 9 of 11

Fig. 8 Gamma-evaluation maps of the three different treatment modalities evaluated using two different gamma passing criteria (the red circle
indicates the area of the 28 mm tumor that is located 1 mm from the brainstem): (a) 3% 3-mm and (b) 5% 1-mm

MLC. Since the setting of MLC’s tolerance table in ma- and dose gradient for tumors of all sizes and locations.
chine’s setting is 1 mm, it means that the machine will According to our results, if a critical organ, such as the
keep delivery as the MLC position error is less than brainstem, is located near the tumor and the situation
1 mm at each control point in the process of delivery, requires a steep dose gradient, the cone-based linac
and that the 1 mm tolerance may affect the measure- should be used for SRT therapy. Since the steep dose
ment results, especially in the small field and high-dose gradient of the cone-based linac is obvious, we should
gradient regions [27, 28]. Therefore the more mechan- also consider using a high dose gradient of the cone base
ical error variable, the more likely to affect the Gamma to treat slightly irregular tumor and protect the critical
pass rate. organs or normal brain. The dose conformity of the
The treatment time of each technique is also the focus FFF-VMAT linac for tumors of all sizes and positions
of our concern. In our study, the longest treatment time was better than that of tomotherapy. The dose gradient
required for the cone-based linac, FFF-VMAT linac and of the FFF-VMAT linac for large tumors (28 mm in
Tomotherapy were 830, 679 and 728 s, respectively. The diameter) was better than that of tomotherapy, whereas
above time did not include the time of image registration tomotherapy had a better dose gradient than the FFF-
and confirmation. For cone-based linac and FFF-VMAT VMAT linac for small tumors (8 mm in diameter). The
linac techniques using the non-coplanar angles, the num- cone-based linac had the smallest 50% and 30% dose
ber of beams that need to rotate the angle of the couch profile widths in the R–L and S–I directions among the
which can affects the time required for treatment. three modalities, with the exception of the 30% dose
profile width for 28 mm tumors in the S–I direction,
Conclusion where tomotherapy and the cone-based linac produced
As a result of the use of spherical tumors, we could not similar results. On one hand, the 30% dose profile
be affected by the shape of the tumor and clearly under- widths of the FFF-VMAT linac in the R–L direction for
stand the differences of the dose characteristics between all tumor volumes were smaller than those of tomother-
three modalities. Among the three treatment modalities apy. Therefore, for protecting normal tissues located su-
studied, the cone-based linac had the best conformity perior and inferior to the tumor, we can consider using
Hsu et al. Radiation Oncology (2017) 12:155 Page 10 of 11

tomotherapy or Cone base with couch at 0 ° for treat- 3. Hazard LJ, Wang B, Skidmore TB, Chern SS, Salter BJ, Jensen RL, et al. Conformity
ment. The TLD and EBT3 measurement results indicate of linac-based stereosurgery radiosurgery using dynamic conformal arcs and
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with steep gradients on the borders of the tumor be- experience with volumetric IMRT (rapidarc) for intracranial stereotactic
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Abbreviations stereotactic radiosurgery using Paddicks gradient index: consideration of the
3D: Three-dimensional; CGI: Conformity/gradient index; CGIc: Conformity optimal method for plan evaluation. J Radiat Res. 2011;52:592–9.
index; CGIg: Gradient index; CIPaddick: Paddick conformity index; 7. Galal MM, Keogh S, Khalil S. Dosimetric and mechanical characteristics of a
CT: Computed-tomography; FFF: Flattening filter-free; GIPaddick: Paddick commercial dynamic μMLC used in SRS. Med Phys. 2011;38:4225–31.
gradient index; HI: Homogeneity index; Linac: Linear accelerator; 8. Audet C, Poffenbarger BA, Chang P, Jackson PS, Lundahl RE, Ryu SI, et al.
MLCs: Multileaf collimators; R–L: Right–left; S–I: Superior–inferior; Evaluation of volumetric modulated arc therapy for cranial radiosurgery
SRS: Stereotactic radiosurgery; SRT: Stereotactic radiotherapy; using multiple noncoplanar arcs. Med Phys. 2011;38:5863–75.
TLD: Thermoluminescent dosimeter; VMAT: Volumetric modulated arc 9. Hong LX, Gard M, Lasala P, Kim M, Mah D, Chen CC, et al. Experience of
therapy micromultileaf collimator linear accelerator based single fraction stereotactic
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Funding radiosurgery of arteriovenous malformations and acoustic neuromas.
This study was supported in part by the Ministry of Science and Technology Radiother Oncol. 2013;106:192–7.
of Taiwan (MOST 104-2314-B-010-040-MY3 and MOST 106-NU-E-010-001-NU). 11. Kaul D, Badakhshi H, Gevaret T, Pasemann D, Budach V, Tuleasca C, et al.
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SMH and YCL designed the project. SMH,YCL, CCJ and CYT contributed to for the treatment of previously irradiated recurrent primary brain tumors and
acquisition of data and data analysis. SMH,YCL and CCJ contributed to brain metastases: Initial report of Radiation Therapy Oncology Group Protocol
methodology of the process. SMH was the Senior Author who oversaw the 90-05. Int J Radiat Oncol Biol Phys. 1996;34:647–54.
project. All authors read and approved the final manuscript. 14. Wagner TH, Bova FJ, Friedman WA, Buatti JM, Bouchet LG, Meeks SL. A
simple and reliable index for scoring rival stereotactic radiosurgery plans. Int
Ethics approval and consent to participate J Radiat Oncol Biol Phys. 2003;57:1141–9.
Not applicable. 15. Paddick I. A simple scoring ratio to index the conformity of radiosurgical
treatment plans. J Neurosurg. 2000;93(Suppl 3):219–22.
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Not applicable. the conformity index. J Neurosurg. 2006;105(Suppl):194–201.
17. Ertl A, Zehetmayer M, Schöggl A, Kindl P, Hartl R. Dosimetry studies with
Competing interests
TLDs for stereotactic radiation techniques for intraocular tumors. Phys Med
The authors declare that they have no competing interests.
Biol. 1997;42:2137–45.
18. Ho AK, Gibbs IC, Chang ST, Main B, Adler JR. The use of TLD and Gafchromic film
Publisher’s Note to assure submillimeter accuracy for image-guided radiosurgery. Med Dosim.
Springer Nature remains neutral with regard to jurisdictional claims in 2008;33:36–41.
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of a modified head and neck quality assurance phantom for use in stereotactic
Author details radiosurgery trials. J Appl Clin Med Phys. 2013;14:206–15.
1 20. Fiandra C, Fusella M, Giglioli FR, Filippi AR, Mantovani C, Ricardi U, et
Medical Physics and Radiation Measurements Laboratory, National
Yang-Ming University, Taipei, Taiwan, ROC. 2Department of Biomedical al. Comparison of Gafchromic EBT2 and EBT3 for patient-specific quality
Imaging and Radiological Sciences, National Yang-Ming University, No. 155, assurance: Cranial stereotactic radiosurgery using volumetric modulated
Sec. 2, Li-Nong St., Beitou District, Taipei 112, Taiwan, ROC. 3Biophotonics arc therapy with multiple noncoplanar arcs. Med Phys. 2013; doi: 10.
and Molecular Imaging Research Center, National Yang-Ming University, 1118/1.4816300.
Taipei, Taiwan, ROC. 4Department of Physics, National Chung Hsing 21. Barbosa NA, da Rosa LA, Batista DV, Carvalho AR. Development of a
University, Taichung, Taiwan, ROC. 5Department of Radiation Oncology, phantom for dose distribution verification in stereotactic radiosurgery. Phys
Changhua Christian Hospital, Changhua, Taiwan, ROC. Med. 2013;29:461–9.
22. Cusmano D, Fumagalli ML, Marchetti M, Fariselli L, De Martin E. Dosimetric
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