Tenzin Yiga

Clinical Practicum III

Esophagus Planning Comparison

For this project I decided to plan the distal esophagus using rapid arc because the original
plan was approved as such. I have not personally worked on an esophagus case prior to this but
my clinic does them using rapid arc or IMRT depending on how the plans look. The patient was
originally prescribed for 25 fractions at 180 cGy/day to a total of 4500 cGy and a boost of 900
cGy in 5 fractions. For this project, the patient is to receive 28 fractions at 180 cGy/day to a total
of 5040 cGy. I will be comparing this rapid arc plan to the IMRT “SupraFirefly” technique
whose instructions were provided in this course.
The final rapid arc plan utilized 2 arcs both at 6MV energy and my dosimetrist suggested
using partial arcs to avoid spinal cord dose. The plan consisted of 1 arc with a clockwise gantry
rotation from 200ᵒ to 160ᵒ and a 15ᵒ collimator angle, the 2nd arc was a counterclockwise gantry
rotation from 160ᵒ to 200ᵒ and a 345ᵒ collimator angle. I didn’t have a constraint template already
set up for the 5040 cGy dose but my plan was able to pass the 4500 cGy dose template so I
didn’t need to scale any of my constraints. I found it difficult to keep my plan from getting
overly hot and the liver and heart mean dose were the most difficult to obtain. Figure 1 and 2
displays the results of my rapid arc plan which was normalized to 100% of the prescribed dose
covering 95% of the tumor volume (per the requirement of this project). The plan had a 3D dose
maximum of 105%.

Figure 1: RapidArc Plan with fields turned on.

Figure 2: RapidArc Plan with fields turned off.

In order to get the best comparison between the rapid arc plan and the IMRT
“SupraFirefly” plan I normalized the same way as the prior plan, 100% of the prescribed dose
covering 95% of the tumor and used the same energy. I added in the suggested 7 gantry angles
which were 60ᵒ, 80ᵒ, 120ᵒ, 140ᵒ, 160ᵒ, 180ᵒ, and 200ᵒ. The “SupaFirefly” technique was intended
to help improve average dosimetric results for the total lung, heart, and liver. After running the
plan through the optimizer my final plan as shown in Figure 3 and 4 had a 3D dose max of
104%.

Figure 3: IMRT “SupaFirefly” with fields on.

Figure 4: IMRT “SupaFirefly” with fields off.

Overall, when comparing the two plans visually I think that the rapid arc plan has a more
controlled 50% IDL overall which can be expected because of the conformality you get when
using arc therapy. For the “SupraFirefly” plan, the beams are mainly coming in from the left side
of the patient so you can clearly see the 50% IDL more heavily on the left side. I’m assuming
this is one way to help control liver dose. When comparing the objectives between rapid arc plan
and “SupraFirefly” plan, they both meet all the objectives as seen in Table 1. The most notable
differences are in the liver, bowel cavity, and duodenum.
Table 1: Comparison of OAR objectives between “SupraFirefly” plan labeled ESO FIREFLY and
the original rapid arc plan labeled ESO RAPIDARC.

Figure 5: DVH comparision between the rapid arc plan dipected by the square and the
“SupraFirefly” technique plan dipected by the triangle.
 At this point we can review things such as minimum dose and low dose to certain OAR
structures on the DVH provided in Figure 5. When looking over the minimum dose to the
organs, there wasn’t much that stood out. The most notable difference was the duodenum dose
which the “SupraFirefly” technique seem to spare more of. This is due to the anterior low dose in
the rapid arc plan being more bowed. This makes sense because of the priority I placed on my
spinal cord. My center does focus on the 50% IDL around the spinal cord, they prefer it to not
wrap around on either side. The fact that the rapid arc plan is cleaner around the spinal cord is
going to affect how the rest of the dose is distributed around the body. When looking closer at
Figure 5, it should also be noted the V5 for total lung is lower in the rapid arc plan. It is about
51% in the rapid arc plan and 56% in the “SupraFirefly” plan.

Even though the “SupraFirefly” plan was cooler and had a lower mean liver dose and
duodenum D30%, I don’t think it is necessarily a better plan compared to the rapid arc plan. I
think both plans are acceptable but in terms of treatment time and other important factors we
consider at this clinic such as the 50% IDL around the spinal cord and kidney doses. I think I
would stick to the rapid arc plan. I do think that this technique was useful for comparison. It was
also fairly quick to generate this plan as well. I think in the future I can try this plan if I am
struggling to meet any of the OAR constraints.