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Neil Joyce
September 21, 2019
DOS 793 Esophagus Plan Study

For this esophageal plan study assignment, comparisons were made between a traditional
beam arrangement used in my clinic and the SupaFirefly technique developed and studied by
Matthew Palmer, CMD, MBA. Outcomes of each plan were analyzed and compared to
determine which planning technique provided better OAR sparing. Treatment planning processes
and plan comparisons with analysis will be followed by a discussion of the findings.
Treatment Planning
For the study, I chose to compare a 3D hybrid plan with the SupaFirefly static IMRT
technique. The 3D plan consisted of AP/PA (16 MV) and 1 DCA (6 MV) beams. Beam angles of
60°, 80°, 120°, 140°, 160°, 180°, and 200° with 6 MV were used for the 7 field SupaFirely static
IMRT plan. The diagnosis for the selected patient was squamous cell carcinoma of the distal
esophagus, stage T3,N0,M0. The prescription dose for both plans was 5040 cGy in 28 fractions,
180 cGy per fraction. The RTOG 1010 dose constraints were used for planning. Both the 3D
hybrid and SupaFirefly static IMRT plans were normalized such that 95% of PTV_5040 received
the prescription dose of 5040 cGy. Treatment planning and dose calculations were performed
using Eclipse TPS version 13.6. The algorithms used for optimization and dose calculations
respectively were Photon Optimizer and AcurosXB. The PTV_5040, liver, heart, lungs, and
spinal cord contours in addition to beam arrangement for each plan are displayed below.
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Neil Joyce
September 21, 2019
DOS 793 Esophagus Plan Study
3D Hybrid Plan Beam Arrangement

SupaFirefly Beam Arrangement

Plan Outcome and Evaluation

Dose volume histograms were evaluated and compared. For both plans studied, the
PTV_5040 was prescribed such that 95% received prescription dose of 5040 cGy. The
SupaFirely plan resulted in a superior conformity index in comparison to the 3D hybrid plan,
with CI of 1.06 and 1.4 respectively. The PTV in this case was superior to the liver, so mean
liver doses were comparable between the 3D hybrid (74 cGy) and SupaFirely (109 cGy) plans.
Large differences in mean heart doses were discovered when analyzing plan results. The mean
heart dose for the 3D hybrid plan was 2167 cGy, with 1178 cGy observed with the SupaFirely
static IMRT plan. Superior lung sparing was noted for the 3D hybrid plan. Mean lung doses were
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Neil Joyce
September 21, 2019
DOS 793 Esophagus Plan Study
found to be 488 cGy for the 3D hybrid plan and 616 cGy in the SupaFirely plan. The maximum
spinal cord dose was found to be less for the SupaFirely plan (446 cGy) in comparison with the
3D hybrid plan (792 cGy). Below are DVH and isodose display comparisons between plans.

Discussion
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Neil Joyce
September 21, 2019
DOS 793 Esophagus Plan Study

The esophagus plan study results exhibited mixed OAR sparing results. The SupaFirely
static IMRT plan contributed less dose to the heart and spinal cord, while giving more to the
lungs and liver OAR as compared to the 3D hybrid plan. Given both plans met the RTOG 1010
dose constraints, both plans would be acceptable to treat a patient with. When selecting between
plans, considerations would need to be made by the physician as to which OAR sparing he or she
would prioritize based on the condition of the patient. The superior reduction in mean heart and
spinal cord doses utilizing the SupaFirefly technique does come with a cost. Increased treatment
delivery time with the 7 field static IMRT SupaFirefly in comparison with alternative techniques
with potential faster treatment such as 3D or VMAT may be considered. The RTOG 1010 dose
constraints with 3D hybrid and SupaFirely plan results are displayed below.
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Neil Joyce
September 21, 2019
DOS 793 Esophagus Plan Study

3D Hybrid Plan Results with RTOG 1010 Dose Constraints

SupaFirely Plan Results with RTOG 1010 Dose Constraints