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Sara Muellerleile
Prof. Neil Joyce
Fieldwork III
September 24, 2021
Esophagus Plan Comparison

The case of an 87yo female with adenocarcinoma of the distal esophagus was chosen to

compare the VMAT technique used most often in my clinical workplace against the

“SupaFirefly” technique presented in a PowerPoint by Matt Palmer, CMD.1 For plan #1, I began

the setup as typically would be done for the TrueBeam at Metro Health – University of Michigan

Health. The GTV and CTV were drawn by the physician. I created a PTV (CTV+1cm) and an

optimization PTV (zPTV = PTV+1mm) to account for downfalls in the Eclipse algorithm to get

dose to the edges of the PTV. In addition, a zPTV-heart+1mm structure was created for

optimization to aid in meeting heart constraints.

Target delineation. CTV in magenta, PTV in Red, zPTV in pink

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With centrally located esophageal targets, two opposite either full or partial arcs are

chosen. In this case, full arcs were chosen to try to achieve a conformal dose distribution while

minimizing the tradeoff between the lung and heart constraints. Eclipse v16 with the AAA

algorithm was used for planning. The axial arcs were set up using the arc geometry tool to move

clockwise with gantry angles from 181º-179º with a collimator of 15º and counterclockwise from

179º to 181º and collimator 345º, respectively. The isocenter was placed in the middle of the

target and clearance was confirmed. The energy used was 6X-FFF with jaw tracking turned on.

Beam arrangement: 2 full, axial arcs

Only a couple rounds of optimization were needed to achieve the goals for this fairly

straightforward plan. I was initially able to push the heart mean as low as 11Gy while meeting

all other objectives, but after initial physician review, it was decided that minimizing lung dose

as much as possible with the tradeoff of losing out on nearing the priority 3 goals of the heart

would be worth a look. Due to the patient’s age, there is a higher concern for short term

pneumonitis vs. heart complications. Therefore, upon further optimization, the lung V20Gy was
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given a higher priority and heart mean priority was reduced. The dose distribution was

conformal and the plan was normalized such that 95% of the PTV volume received the

prescription. Upon final review, the physician was pleased with the dose distribution and OAR

doses.

Optimization objectives

Plan #1 VMAT dose distribution. Rx=yellow IDL, 95%Rx=blue IDL

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Plan #1 Goals – Green = goal met, Orange = priority 3 goal not met
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For plan #2, the SupaFirefly technique was used with the same planning system,

calculation algorithm, energy and constraint goals. The isocenter was again placed in the middle

of the PTV (same location as plan #1). The gantry angles used per this technique were as

follows: 60º, 80º, 120º, 140º, 160º, 180º, and 210º. Jaw tracking was left on and the same

optimization objectives as the VMAT plan were copied over in the optimizer. I left the NTO

setting the same, just to see try to push this IMRT technique to be as conformal as possible to

compare the VMAT achievements of plan #1. The plan was again normalized such that 95% of

the PTV was receiving the prescription dose and constraint goals were verified.

SupaFirefly technique beam arrangement

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NTO settings

Plan #2 Dose distribution. Rx = yellow IDL, 95%Rx = blue IDL

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Plan #2 Goals – Green = goals met, Orange = priority 3 goals not met

Upon comparison of the two techniques, it was found that they were overall very similar.

There were tradeoffs in the dose distribution that were predictably most noticeable for low doses.

With the VMAT plan, the doses were more circular and conformal to the PTV, with more of the

20Gy line equally in both lungs. With the SupaFly technique, the 20Gy IDL sticks mostly to the

left side, but extends our further resulting in very similar V20Gy % values for the lungs. The
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lung mean dose was essentially the same for both plans, and the V20Gy showed a 1% increase

from the VMAT 18.4% to SupaFly 19.6%. The heart mean was slightly lower with the VMAT

plan at 17Gy, while 18.5Gy with the SupaFirefly technique. The liver mean did decrease by

1.7Gy with the SupaFly technique. The overall PTV coverage results were nearly identical.

Dose distribution comparison –VMAT on left, SupaFly on right

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Goals –plan #1 VMAT on left, Plan #2 SupaFly on right

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Based on the results from this case, I cannot fully conclude that the SupaFirefly technique

is superior to VMAT. It certainly gives a desirable arrangement of angles aimed at sparing the

heart, lungs and liver. In addition, it has the potential to spread less low dose around as may

occur with a VMAT plan. Moreover, the techniques used here were very comparable. I did find

this arrangement to be helpful and something I may use clinically if there is difficulty in sparing

certain OARs. It seems that at my clinic we jumped from a standard 4-field 3DCRT beam

arrangement to VMAT arcs without ever exploring IMRT arrangements in between. Learning

this technique was helpful as it gives me one more tool for difficult cases in the future.
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References

1. Palmer M. Advances in Treatment Planning Techniques and Technologies for Esophagus

Cancer. [PowerPoint]. UW-L Medical Dosimetry Program; 2021.