Esophagus SupraFirefly Plan Comparison

Treatment of esophageal cancer can be very challenging. There are many critical organs
surrounding the esophagus that dosimetrists need to spare. In the past, there have been many different
techniques used to try to accomplish this. This semester we were instructed to choose a previously
planned esophageal patient at our clinic and re-plan them using Matt Palmer’s SupraFirefly technique.
This technique was created to help spare critical organs such as the heart, liver, and lungs. When
completed, both plans are to be compared side by side for evaluation of these critical structures.

I began this assignment by reviewing Matt Palmers power point presentation on the SupraFirefly
technique. The main goal was to use his beam arrangement provided to treat esophageal cancer as well
as spare organs like the heart, liver and lungs. While watching the presentation, I was a bit surprised to
see him use a 4D scan to help create the treated volumes. This is something that I have never seen used
in a clinic before for treating esophageal cancer. After reviewing our records and talking with our
physicians, I found this was the case in our clinic. I then decided to find a patient that would best
represent the same total PTV volume that Matt indicated in his presentation. I chose a patient that was
previously treated with VMAT to a larger esophageal tumor volume. I felt this patient would display the
best plan comparison.

I started by reviewing the isocenter placement of the VMAT plan. We had already placed the
isocenter in the center of the PTV, so I left it there. The plan consisted of two full arcs with a 20°
collimator angle, and the table at 0°. The Acuros algorithm was used for calculation with 6MV photons.
The plan was prescribed for 28 fractions at 180cGy per fraction, total dose 5040cGy. It was already
normalized to 100% of the dose covering 95% of the PTV volume. Our clinics dose constraints were
used while optimizing. In our clinic we use the RTOG 1010 protocol for the liver, kidneys, heart, total
lung and spinal cord.
 VMAT fields and monitor units are shown below.

To compare the SupraFirefly technique I made a template of the VMAT optimization and used it
to calculate the SupraFirefly plan. I placed the isocenter in the center of the PTV volume. The beam
angles for this plan were 60°,80°,120°,140°,160°,180° and 200°. All fields had a collimator and table
angle at 0°. When the optimization was completed, I changed the prescription to match the VMAT plan;
100% coverage to 95% PTV volume. Displayed below is the field arrangement along with monitor
units.

After both plans were completed, I ran a comparison of the dose volume histogram (DVH). I was
surprised at the results. Structures such as the liver, heart and lungs were very comparable with both
planning techniques, however the liver and lungs were found to be spared more with the SupraFireFly
technique. The heart dose was almost identical for each technique. Other critical structures such as the
heart minus the PTV, kidneys and spinal cord also had a similar dose distribution between the plans.
 Pictured below are plan comparison DVHs of the important organs.

This DVH represents the dose comparison of Liver volume.

- -VMAT plan: Mean dose to Total Liver Volume -17.4%.

- SupraFirefly Technique: Mean dose to Total Liver Volume -14.2%.

This DVH represents the dose comparison of Total Lung volume.

- -VMAT plan: Mean dose to Total Lung Volume -27.2%.

- SupraFirefly Technique: Mean dose to Total Lung Volume -27.1%.

This DVH represents the dose comparison of Heart volume.

- -VMAT plan: Mean dose to Heart Volume -39.5%.

- SupraFirefly Technique: Mean dose to Total Heart Volume -39.9%.

Below is a plan comparison DVH of other important organs within the area of the treatment.
All constraints were met with both planning techniques. This table represents the comparison outcome of doses
given between VMAT and Suprafirefly plans.

OAR Limit(cGy) VMAT Dose SupraFireFly Dose

Spinal Cord +5mm 4800Gy 1504cGy 1904cGy
Spinal Cord Max Dose 4000cGy 1370cGy 1540cGy
Heart Mean 2100cGy 1992cGy 2010cGy
Heart 50% Volume 4000cGy 1644cGy 1756cGy
Liver 60% Volume 3000cGy 310cGy 383cGy
Liver Mean 2500cGy 877.1cGy 714.9cGy

Kidney 70% Volume 2000cGy 66cGy 64cGy

Lung 20% Volume 3000cGy 1852cGy 2058cGy
Lung 30% Volume 2000cGy 1594cGy 1758cGy

Lung Mean 2000cGy 1371.2cGy 1363.8cGy

The plan PTV coverage was nearly identical for each plan. The mean PTV dose was 5193cGy
(103.0%) for the VMAT plan, 5209cGy (103.4%) with the SupraFireFly. The hotspot on the VMAT
plan was 110.8%. The Hotspot for the SupraFirefly technique was very similar at 109.2%. The
minimum 3D dose was almost identical. The SupraFireFly plan seemed to be more homogeneous
throughout the PTV.

Below are side by side comparisons of the VMAT and SupraFireFly techniques with color wash
doses in the axial, sagittal and frontal planes.
 VMAT SupraFireFly

The most significant difference between the VMAT and the SupraFireFly technique will be the
treatment time it will take to deliver. The VMAT plan had fewer monitor units and gantry angles. There
will be less imaging as well with the VMAT plan which would also decrease treatment time and
radiation exposure. The patient’s time on the treatment table is going to be significantly less with this
plan. I feel for this reason, our clinic would opt for this planning technique.

This assignment was a great way to compare two different techniques to treat esophageal cancer,
especially since medical dosimetry is constantly evolving. The outcome of the SupraFirefly technique
plan was very comparable to the VMAT plan. The Suprafirefly plan showed it can be used to spare
organs similar to a VMAT plan. This technique even displayed less dose to structures such as the lung
and liver. The dose was comparable to all other structures including the heart and kidneys. I feel the
strategic beam arrangement Matt developed is very useful in planning esophageal patients. I enjoyed this
assignment and will try to implement the SurpaFireFly technique in proper situations.