Dakota Sturgess

Clinical Practicum III

Esophagus VMAT vs SupaFirefly Technique

The purpose of this assignment was to compare a standard approach used at my clinical
site, Michigan Medicine, to the SupaFirefly planning technique. To compare these plans, both
planning methods utilized the same CT data set, isocenter location, target contours, organs at risk
(OAR), prescription, energy, and plan normalization. The difference between the methods is the
beam arrangements. The prescription used was a total dose of 50.4 Gy for 28 fractions, 1.8 Gy
per fraction. For both plans, 6 MV photon energy was used, and the plans were normalized so
that 100% of the prescription dose cover 95% of the planning target volume (PTV).

At Michigan Medicine, a typical planning approach for an esophageal patient is to use 2-

3 full arc rotations, utilizing volumetrically modulated arc therapy (VMAT). For this case, I used
three full arcs, two clockwise arcs rotating from 181° to 179°, and one counterclockwise arc
rotation 179° to 181°. The collimator angles used were 10°, 350°, and 95°. I created optimization
structures due to the overlap of the PTV.

The SupaFirefly is a step and shoot IMRT technique. This plan used the same
optimization parameters and structures, the only difference was the beam arrangements. The
beam angles used 60, 80, 120, 140, 160, 180, and 200.

Figure 1. Plan objectives and outcomes.

Organ at Risk Planning Objective VMAT Outcome SupaFirefly Outcome

PTV V100%95% 99.67% 98.91%
Spinal Canal Max=45 Gy 29.16% 35.63%
Lungs Mean< 15 Gy 12.1% 11.24%
V20 Gy < 25% 22.4% 18.5%
V5 Gy<65% 63.68% 65.58%
Heart V30 Gy<100% 22.35% 22.69%
V40 Gy<50% 7.65% 6.83%
Mean<30 Gy 18.63% 20.5%
Kidneys V18 Gy <33% 26.39% 30.97%
Liver Mean <21 Gy 19.29% 16.29%
V30 Gy<30% 12.97% 12.88%
 Below in figure 2 is the dose volume histogram of the two plans overlayed. Both plans
would be acceptable plans, but the VMAT plan looks more conformal with slightly better
coverage. The biggest difference that I noticed was the V20Gy of the right lung and the liver
mean dose, where the SupaFirefly technique would be superior to the VMAT plan. The
SupaFirefly, compared to the VMAT plan, that I did not like was the 50% IDL conformity.
Below in Figure 3 you can see the 50% IDL of the two plans.

Figure 2. DVH Overlay of SupaFirefly plan (squares) and VMAT plan (triangles).

Figure 3. Isodose Conformity comparison.

 SupaFirefly VMAT

After comparing the two plans, I do not believe the SupaFirefly technique is superior to
the VMAT plan. The main reason is because of the dose streaking into the lungs and surrounding
tissues. I tried using a ring to help with the conformity of the SupaFirefly technique but did not
make a significant difference. The advantage of the VMAT plan is that it produces a more
conformal outcome. The main advantage for the Supafirefly is that it allows you to avoid
structures. There are tradeoffs with each of these plans, however, I believe the VMAT technique
was more beneficial in this case.

Reference:
1. Palmer M. Advances in Treatment Planning Techniques and Technologies for Esophagus
Cancer. [PowerPoint]. Houston, TX: The University of TexasMD Anderson Cancer
Center