Rodger Williams

September 15, 2018

DOS 793 Field Work III

Comparison of Esophageal Treatment Delivery

Delivery of radiation treatment for esophageal cancer can be accomplished with a variety
of techniques. Using 3-D, to IMRT to VMAT planning, all three are acceptable methods of
obtaining a quality plan and achieving the planning constraints acceptable to protocol1. This
discussion will compare the technique referenced by Palmer’s2 SupaFirefly technique to the
current acceptable method utilized in our clinic.
Up until recently, our clinic used 3-D technique to deliver a total dose of 50.4 Gy to the
esophageal Planning Treatment Volume (PTV). Recently we installed a TureBeam that can
deliver VMAT plans created with eclipse version 13.6. This utilizes the AAA (Anisotropic
Analytical Algorithm) algorithm. The use of two full rotations were used. The first arc starts at
181˚ and stops at 215˚. From 215˚ to 40˚ is a programmed skip. It starts up again at 40˚ and
stops at 179˚. The next arc is the reversal of the first arc. This beam configuration allows for the
delivery of the dose to the esophagus while protection the heart and liver. Palmer’s technique
delivers the treatment in a very similar fashion starting his first angle at 60˚ and ending at 200˚.
His angles are in 20˚ increments with the exception between 80˚ and 120˚. There is a 40˚
separation between these two angles. Seven beams are used to deliver this technique. This uses
static step and shoot IMRT.
We follow constraints from RTOG -1131 protocol for the PTV, heart, lungs, spinal cord
and liver. The dose constraints for the kidneys follow the QUANTEC3 data. We also consider
the dose to both kidneys because our fields commonly go inferiorly to the gastric cardia.
Displayed below are the graphic dose distributions comparing the VMAT plan to the
SupaFirefly plan. The DVH graph will illustrate the dose to the organs at risk and the coverage to
the PTV.
SupaFirefly dose distribution

VMAT dose distribution

 DVH comparison
■ = SupaFirefly
▲ = VMAT

Planning Constraints
Organ Volume Dose (Gy)
PTV >95% 50.4
Heart 1/3 50
2/3 45
3/3 40
Lungs 5 50
10 45
20 35
mean 20
Spinal Cord 0 45
Liver 1/2 35
2/2 30
Kidneys mean 15

Review of data: All constraints were met using both techniques. Items that were noteworthy:
the overall hotspot for the SupaFirefly plan was 3% lower than the VMAT plan, 105.9% to
108.9% respective. The dose distribution was more homogeneous and conformal for the for the
SupaFirefly technique are advantageous for creating a plan that meets the planning criteria and
has better conformity and homogeneous coverage. This was a valuable exercise to learn a new
technique for the treatment of esophageal cancer.

References
1. Non-operative therapy of local-regional carcinoma of the esophagus: a randomized phase
II study of two paclitaxel-based chemotherapy regimens.
https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?action
2. Palmer M. Advances in treatment planning techniques and technologies for esophagus
cancer. accessed September 15, 218
3. Marks, LB, Yorke, ED, Jackson, A, et al. Use of normal tissue complication probability
models in the clinic. Int. J. Radiation Oncology Biol. Phys. Vol. 76, No. 3, Supplement,
pp. S10–S19. https://doi:10.1016/j.ijrobp.2009.07.1754.