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Stephanie Sanford
Clinical Practicum III
Esophagus Planning Project

In my clinical internship facility, esophageal cases are generally planned with a VMAT
method. I chose to create the Supa Firefly trial and compare it to a recently treated VMAT
esophagus plan created in our clinic. The VMAT plan utilized two full arcs to deliver the
treatment as opposed to the 7 fields outlined in the Supa Firefly technique of 60, 80, 120,
140, 160, 180, and 200.1
In the VMAT plan utilized for treatment, all objectives outlined in the treatment planning
directive were met with the exception of one constraint that was met by a secondary goal set by
the physician. The Supa Firefly method was able to meet all objectives and constraints outlined
in the treatment planning directive. Of the 22 goals outlined by the physician the VMAT plan
outperformed the Supa Firefly method in 11 of these goals. The remaining 11 goals were
superiorly met in the Supa Firefly plan. Most metrics were very closely matched in each trial.
The largest area of concern for the Supa Firefly plan was seen in the kidney dose being higher
due to the beams being directly placed in line with the organ at risk. I feel as far as planning
goals these two methods are quite fairly matched. In the following table the superiorly
performing score is shaded in green. The primary goal not met by the VMAT plan is seen in
yellow.
Table 1. Treatment Planning Directive Goals and Scores for VMAT and Supa Firefly plans

ROI Objective or Constraint VMAT Supa Firefly

Spinal
Cord Max Dose 45Gy 4251 cGy 4462 cGy
Total Lung V30 under20% 5% 4.7%
Total Lung V20 under 25% 14.20% 15.20%
Total Lung V10 under 40% 26.20% 31.10%
Total Lung V5 under 50% 45.20% 49.40%
Total Lung Mean Dose under 20Gy 888 cGy 927 cGy
Heart V40 under 25% 16.50% 15.00%
Heart V30 under 35% 33.10% 31.40%
Liver V30 under 33% 2.70% 1.90%
Liver V20 under 50% 11.10% 5.50%
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Liver Mean Dose under 30Gy 993 cGy 825 cGy

Kidney_L V20 under 33% 7.50% 24.80%
Kidney_L Mean Dose under 18Gy 714 cGy 1014 cGy
Kidney_R V20 under 33% 15.80% 12.10%
Kidney_R Mean Dose under 18Gy 1131 cGy 1325 cGy
PTV to receive at least 95% of the Rx Dose 95.30% 95.90%
no more than 10% of the PTV to receive
PTV 105% of the Rx Dose 14.30% 5.90%
PTV Max point dose to the PTV of 110% 5486 cGy 5540 cGy
CTV to receive at least 98% of the Rx Dose 100% 100%
Stomach Max dose of 54Gy 5350 cGy 5322 cGy
Duodenum Max dose of 54Gy 5016 cGy 5064 cGy
Small
Bowel Max dose of 54Gy 5231 cGy 5111 cGy
Large
Bowel Max dose of 54Gy 5275 cGy 5289 cGy

When reviewing the plan visually conformality is quite similar but you can see that each
planner did choose to push on different critical structures more than others in the optimizer
which caused dose spill to spread to different areas of the body.
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Figure 1. Comparison axial views are shown with the VMAT plan on the left and the Supa
Firefly plan on the right.
After completing this plan, I reviewed both trials with the dosimetrist that had created the
VMAT plan originally. We discussed some of the pros and cons of each plan and what things
would be overall preferred for treatment delivery. An advantage seen on the Supa Firefly
technique would be that you can control where dose will be delivered better in that if you had to
plan around a pacemaker you could make sure that no beams would enter or exit through the
device to limit dose to this sensitive piece of equipment. The planning time is also considerably
shorter with the Supa Firefly technique. VMAT planning does take more time and if a quick
turnaround for planning is required to get the patient started an IMRT approach may be advised.
These cases, however, are generally given at least a week of planning time and there is usually
not a concern to complete a VMAT plan in that amount of time. Treatment delivery time is also
a factor to consider. It generally takes less time for the therapists to treat two VMAT arcs than
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seven IMRT fields. Because we want to make sure the treatment is delivered as accurately as
possible we want the time between imaging localization and treatment delivery as minimal as
possible to limit the opportunity for the patient to move. In this case the target is midline and
worries about table collisions are generally not of concern for these full arc fields but this might
also be something to consider when creating a beam arrangement for treatment delivery.
Furthermore, if a treatment couch is being utilized that has bars to be moved in and out during
treatments this may also factor into the decision for arc angles or beam angles. All of our
treatment couches are the new style and this is not of concern but it was discussed in our review
for consideration. One of the last items discussed was treatments requiring breath hold. If a
breath hold technique is needed, the shorter treatment delivery per field in the Supa Firefly
technique may be superior for patient comfort. Esophagus cases are generally treated free
breathing in our centers so this is also not of concern however it is something to be considered
when devising a treatment plan in the thoracic region.
In conclusion, it was decided that a physician would likely choose the VMAT plan over
the Supa Firefly technique to keep things more consistent with what is routinely done in the
clinics as well as efficiency of time for treatment delivery given that most metrics are fairly
similar. Depending on the specifics of the case there may be constraints that are more priority
specific to that patients history so each case should be uniquely considered. We both felt that
each plan would be clinically acceptable treatment plans. There are many factors to consider
when devising beam arrangements for a treatment plan and being aware of different planning
techniques will give me more options when devising the optimal plan for my patients.
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Figure 2. DVH parameters comparing the VMAT and Supa Firefly plans
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Figure 3. DVH parameters comparing the VMAT and Supa Firefly plans
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Figure 4. DVH parameters comparing the VMAT and Supa Firefly plans
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Figure 5. DVH parameters comparing the VMAT and Supa Firefly plans
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References
1. Palmer M. Advances in Treatment Planning and Technologies for Esophagus Cancer. AAMD.
Accessed November 1, 2017.