Nathan Jones

September 2019

DOS 293 Fieldwork III

Esophageal Treatment: Planning Comparisons

This assignment aimed at evaluating Matt Palmer’s SupaFireFly beam arrangement versus
traditional methods for treating esophageal cancers. I chose a patient that had been previously treated
using a hemi static field arrangement. Below on the right is the seven beam arrangement
recommended by Palmer which uses gantry angles of 60, 80, 120, 140, 160, 180 and 200 degrees with
no couch kicks. On the left is a traditional 3D unilateral beam arrangement used to treat this patient.
This plan consisted of fields with angles of 350, 30, 70, 110 and 180 degrees with no couch kicks.

The constraints for this patient were taken from the RTOG 1010 protocol. The target was prescribed
180cGy for 28fx to 5040cGy. The organs at risk are the lungs, heart, liver, spinal cord and kidneys. The
kidneys were not a factor in this particular plan since they were far below the treatment area. Although
the superior portion of the liver was in the treatment field, I had no difficulty meeting the constraints for
this particular plan. Since the heart, lungs and spinal cord were located at the level of the target, there
was a reasonable amount of dose contribution to them in this plan. Below is a copy of the RTOG 1010
dose constraints used for this patient.
Traditional 5-field Plan

The 5 field 3D plan was weighted slightly higher anteriorly and posteriorly in order to decrease the lung
dose peripherally. This naturally increased the dose to the heart and spinal cord.

Below you can see a fair amount of the 50% isodose line being delivered through the heart and spine.

Although the dose was increased to the heart and spine, the traditional beam arrangement was able to
meet the coverage and OAR dose constraints.
SupaFireFly Technique

Matt Palmer’s posterior-lateral beam arrangement using IMRT technique avoids entering through the
heart and allows the dose to be modulated posteriorly which helped to decrease the dose to the spinal
cord. Below are a few illustrations showing the dose being spread out posteriorly and laterally. I was
impressed at how this technique eliminated a large amount of the 50% isodose distribution seen in the
traditional 5-field arrangement.
Using IMRT to modulate the dose to the critical organs certainly helped to further decrease the dose to
the heart, lungs and spinal cord while delivering dose to the target. Below are the objectives and
priorities I used for optimizing the SupaFireFly technique.

Using IMRT and Matt Palmer’s beam arrangement, I was able to easily meet all the RTOG 1010
objectives with room to spare. Below is the scorecard showing the planning metrics achieved using the
SupaFireFly technique.
Plan Comparison: Traditional versus SupaFireFly

Although both planning techniques were able to meet the RTOG 1010 constraints, I felt the SupaFireFly
technique was superior to the traditional hemi field arrangement used to treat this patient. The
following DVH comparison show the disparities of the traditional arrangement (triangle) compared to
the SupaFireFly technique (square).

Both techniques were able to successfully cover the target as seen below. The SupaFireFly was able to
create a more homogenous dose distribution using modulation.

PTV 50.4

The total lung was comparable between the two techniques however the SupaFireFly technique
provided slightly lower doses for each constraint.
 Total Lung

The dose to the kidneys was negligible due to their location to the treatment field, however you can see
the dose is slightly lower using the SupaFireFly technique.

Kidneys

The relative dose to the liver was also very low but again was lower with the SupaFireFly technique.

Liver
The greatest improvement using Matt Palmer’s technique was seen in the dose to the heart and spinal
cord. Eliminating the anterior beams and entrance dose decreased the dose to the heart significantly.

Heart

The spinal cord max was decreased from 44Gy to 33Gy using the SupaFireFly technique which was
impressive to me since the majority of the beams were posterior. The ability to modulate around the
spine with IMRT technique was very helpful in improving this metric.

Spinal Cord

Conclusions

I was very impressed with Matt Palmer’s esophagus technique. The doses to all the normal structures
were decreased using his beam arrangement. I was especially surprised at the difference in dose
contribution to the heart and spinal cord in comparison to traditional techniques. I am glad to have this
technique in my planning arsenal and will certainly consider implementing it in future cases.