Kyle Garafolo

DOS 773 Clinical Practicum III

September 18, 2019
SupaFireFly Esophagus Plan Comparison
Background
For this assignment, students were asked to create two separate treatment plans for a
previously treated esophageal cancer patient. The first plan was to be developed using a
commonly used technique and organ at risk (OAR) objectives used at my clinical site. The
second plan was to be developed using the SupaFireFly technique per recommendations found in
a PowerPoint presentation by Matt Palmer1. The prescribed radiation dose for both plans was to
be 28 fractions at 1.8 Gy per fraction, for a total dose of 50.4 Gy. Both plans were then to be
normalized so that 95% of the target received 100% of the prescription dose. This would ensure
an equal comparison could be performed between both treatment planning techniques.
The patient I selected for this assignment was a previously treated patient diagnosed with
cancer of the distal esophagus. The patient received a CT simulation on the wing board with both
his arms up. The gross tumor volume (GTV), clinical target volume (CTV), and planning target
volume (PTV) were all contoured by the attending radiation oncologist (figure 1).

Figure 1: Axial, coronal, and sagittal views of the GTV (red), CTV (green) and PTV (Blue)

Treatment planning – Commonly used technique at clinical site

At my clinical site, the commonly used technique for planning esophageal cancers is to
use 2 to 3 full arcs using volumetric modulated arc therapy (VMAT), or commonly known as
RapidArc Radiotherapy Technology for Varian treatment machines. For this assignment, I opted
to use 2 full arcs covering the entirety of the PTV (Figure 2). The first arc rotated clockwise from
181° to 179° with a 350° collimator rotation. The second arc rotated counterclockwise from 179°
to 181° with a 10° collimator rotation (figure 3). Both arcs were created with 6 MV energy. Prior
to plan optimization, I created several structures to assist in controlling dose. These structures
included a PTV_esophagus_opti, PTV_heart_overlap, PTV_stomach_overlap, Heart_Avoid,
Stomach_Avoid, and LungsLessPTV. During plan optimization, I focused on achieving adequate
coverage to the all the PTV structures, while trying to reduce regions of maximum dose within
the overlap structures. Additionally, I used either upper and/or mean objectives for the nearby
OAR to satisfy dose constraint criteria.

Figure 2: RapidArc field orientation

Figure 3: RapidArc field information

Treatment planning – SupaFireFly technique
For the SupaFireFly technique, I followed the field design recommendations found in the
presentation by Matt Palmer.1 This process included creating 7 static field IMRT beams with
corresponding gantry angles at 60°, 80°, 120°, 140°, 160°, 180°, and 200° all with the collimator
at 0° (figures 4 and 5). Each field contained the entirety of the PTV structure and had an energy
of 6 MV. Plan optimization followed the same process as in the RapidArc technique used.
Because I knew both plans would ultimately be normalized to achieve the same target coverage
for equal comparison, I was able to fully “push” the optimizer for each plan separately in order to
achieve my desired outcomes.

Figure 4: SupaFireFly field orientation

Figure 5: SupaFireFly field information

Results
Upon completion of optimization, dose was calculated and both treatment plans were
normalized so that 95% of the target received 100% of the prescription dose. Organ-at-risk
constraints, the dose-volume histogram (DVH), structure dose statistics, and dose colorwash
depictions were then compared (figures 6-10).

Constraint Result
Lung (combined) Less PTV RapidArc SupaFireFly
Mean ≤ 1800 cGy 960.2 cGy 896.6 cGy
V3000 cGy ≤ 20% 3.46% 4.25%
V2000 cGy ≤ 30% 12.89% 14.79%
V1000 cGy ≤ 40% 41.41% 31.29%
V500 cGy ≤ 60% 53.23% 50.71%
Liver
Mean ≤ 2000 cGy 1505.6 cGy 1152.8 cGy
V3500 ≤ 40% 5.94% 4.38%
Kidneys
V2000 cGy ≤ 67% (each) Right: 8.43% Right: 4.23%
Left: 7.17% Left: 36.78
V1500 cGy ≤100% (combined) 29.05% 25.23%
Spinal Cord
V5000 cGy ≤ 1% 0% 0%
V4500 cGy ≤ 5% 0% 0%
Heart
Mean ≤ 3000 cGy 2069.7 cGy 1926.5 cGy
Figure 6: OAR constraints and results for RapidArc and SupaFireFly planning techniques
Figure 7a: SupaFireFly and RapidArc DVH comparison of some structures
Figure 7b: SupaFireFly and RapidArc DVH comparison of some structures
Figure 8: SupaFireFly (square) and RapidArc (triangle) structure dose statistics
 RapidArc SupaFireFly

Figure 9: Colorwash comparison of ≥ 2520 cGy (50% dose) between RapidArc and SupaFireFly planning techniques
 RapidArc SupaFireFly

Figure 10: Colorwash comparison of ≥ 1000 cGy (~ 20% dose) between RapidArc and SupaFireFly planning techniques
Discussion
After reviewing the results for both normalized treatment plans, several observations
were made. The global maximum dose for the RapidArc plan was 5279 cGy (104.7%) as
compared to 5206 cGy (103.3%) with the SupaFireFly plan. All dose constraints were met for
both planning techniques, except V1000 cGy ≤ 40% for the RapidArc plan (41.41%). While both
treatment planning techniques produced clinically acceptable plans, the SupaFireFly plan
generally produced more favorable results in terms of dose to nearby OAR. In my opinion, this
can likely be attributed to the mainly left sided fields entering the patient, which greatly reduced
the low dose to the patient’s right side as compared to the RapidArc plan (figure 10). While the
RapidArc plan was more conformal in the high dose region, it did produce more spread-out dose
throughout the entirety of the patient. This resulted in greater maximum and mean dose to many
of the OAR (figures 6 & 8). Of note, the SupaFireFly plan did exhibit less mean dose to the
heart, lungs, and liver as expected. In achieving this, however, it also increased dose to the left
kidney, spinal cord, and stomach (although all still within dose constraints).
Besides dose, there are other factors that must be considered when reviewing these
two treatment plans. The RapidArc plan will result in a faster treatment than the 7 static-field
IMRT (SupaFireFly) plan. This means less time on the treatment table for the patient, which can
translate to not only more comfort but potentially less patient movement. This is an important
factor to consider especially with older patients. However, if the patient had prior radiation and
meeting specific dose constraints was paramount, then the SupaFireFly technique would
certainly be a helpful option to consider. I believe that the SupaFireFly plan was slightly superior
than the RapidArc plan due to its ability to reduce dose to many of the OAR. Ultimately, both
plans produced clinically acceptable results and could be great options depending on patient
circumstances. That being said, I believe my clinic would still likely prefer the RapidArc plan
due to its ability to meet dose constraints, produce faster treatment times, and improve patient
comfort.
 References
1. Palmer, M. Advances in Treatment Planning Techniques and Technologies for
Esophagus Cancer. PowerPoint]. Houston, TX: MD Anderson Cancer Center. Accessed
September 12, 2019.