Seth Crumpton

SupaFirefly Assignment
November 1, 2017
At my clinical site at Austin Cancer Centers we typically treat esophageal cancer using dual arc
VMAT beams with a primary dose of 45Gy that is then boosted to a dose of 50.4Gy. For the
purposes of this assignment I chose to compare the SupaFirefly esophagus treatment plan
technique to a previously treated VMAT plan that was used in my clinical site in an esophageal
case. At my clinical site we use a score card of dose volume histogram limits that are sponsored
by Mobius3D to verify organs at risk dose constraints are met. The table below represents the
goal of each organ at risk and the results for each plan.
Target Volume Goal VMAT Plan SupaFirefly Result/Difference
GTV 50.4Gy=100% 100% 100% Same
Vol
CTV 50.4=100% Vol 100% 100% Same
PTV 50.4Gy=95% 100% 99% VMAT- 1%
Vol
PTV 47.88Gy=100% 100% 100% Same
Organ at Risk Dose limit
Heart 33%<60Gy 0% 0% Same
Heart 67%<45Gy 13% 9% SupaFirefly-4%
Heart 100%<40Gy 17% 12% SupaFirefly-5%
Lung Mean 5.81Gy 5.16Gy SupaFirefly-
Dose<20Gy .65Gy
Lung 37%<20Gy 6% 8% VMAT-2%
Spinal Cord Max 33.80Gy 35.6Gy VMAT-1.8Gy
Dose<45Gy
Liver 50%<35Gy 9% 6% SupaFirefly-3%
Liver 100%<30Gy 13% 8% SupaFirefly-5%
Rt Kidney 33%<50Gy 0% 0% Same
Rt Kidney 67%<30Gy 0% 0% Same
Rt Kidney 100%<23Gy 0% 6% VMAT-6%
Lt Kidney 33%<50Gy 0% 0% Same
Lt Kidney 67%<30Gy 3% 8% VMAT-5%
Lt Kidney 100%<23Gy 9% 16% VMAT-7%
Stomach Max 52.63Gy 53.45Gy VMAT-.82Gy
Dose<54Gy
Global Max <110% 106% 108% VMAT-2%

As you can see from the table above. All twenty constraints were met by both the SupaFirefly
plan and the VMAT plan. There was very little difference between the target volume coverage of
each plan. In fact, the only difference between these four constraints occurred in the PTV that
had a goal of 95% coverage by the 50.4Gy isodose line and this was just about 1% loss in
coverage for the SupaFirefly plan. Of the remaining sixteen constraints remaining, the
SupaFirefly plan was superior in five of them, the VMAT plan was superior in seven of them and
last four showed no variation between the two plans. The most important variations between the
plans occurred in the heart dose, spinal cord max dose, liver dose, lt kidney dose and the hotspot.
Seth Crumpton
SupaFirefly Assignment
November 1, 2017
If you assess these constraints, you can generalize that the SupaFirefly limited dose better in the
heart and liver, while the VMAT plan limited dose better in the spinal cord and lt kidney.
Therefore, if it is a priority to limit dose in the heart or liver, SupaFirefly seems to be a superior
technique that will allow the dosimetrist to effectively treat the esophagus target volume while
limiting the dose to the heart and liver.
To achieve the VMAT plan, I had to convert the original plan from 45Gy to a boost of 50.4Gy to
a prescription with a primary dose of 50.4Gy without the boost to meet the requirements of the
assignment. I was able to achieve two plans that met all constraints by using the following
constraints in the optimizer listed in the table below.

Each plan was run through the optimizer four times until all constraints were met and both plans
were normalized to 96%. While the first table I listed can be used as a basic tool to evaluate the
two plans I dont feel it effectively shows the difference between them. The variation of the two
plans is more evident in the isodose line coverage viewed in the three planes.
Seth Crumpton
SupaFirefly Assignment
November 1, 2017

As you can see in the axial slice the VMAT plan (left) appears more uniform and circular, while
the lower dose isodose lines appear jagged in the SupaFirefly plan(right). Also, note that in the
SupaFirefly plan that lower dose isodose line coverage increases along the posterior left portion
the patient, while the lower dose isodose lines in the VMAT plan increase along the anterior
portion of the patient. This would explain why the liver dose and heart dose decrease with
SupaFirefly plans.
Seth Crumpton
SupaFirefly Assignment
November 1, 2017

In the saggital plane you can once again see that the 2520 (pink) isodose line increases along the
anterior portion of the patient in the VMAT plan. Also, note that the 3528 (blue) isodose line is
not uniform and increases posteriorly in some of the slices for the SupaFirefly plan. There are a
lot more 5292 (orage) isodose hot spots occurring in the SupaFirefly plan as well.
Seth Crumpton
SupaFirefly Assignment
November 1, 2017

In the coronal plane the VMAT isodose lines again appear more uniform to the shape of the
PTV, but notice how broad they are encompassing large portions of the heart and liver. In
comparison the SupaFirefly isodose line appear to more tightly encompass the PTV and dips
significatntly in the hear suggesting reduced dose there. This also occurs slightly in the liver
when comparing the VMAT plan to the SupaFirefly plan.
Seth Crumpton
SupaFirefly Assignment
November 1, 2017

The hotspot for the VMAT plan occurs on the posterior right portion of the PTV and is also
located on the superior portion. The max of the hotspot is 5329cGy (106%).
Seth Crumpton
SupaFirefly Assignment
November 1, 2017

The hotspot that occurs in the SupaFirefly plan occurs more superior when compared to the
VMAT plan, but again occurs in the posterior right portion of the PTV. The max of the hotspot is
5469cGy (108%).
The most significant variation of dose can be observed in the dose volume histogram below.
Seth Crumpton
SupaFirefly Assignment
November 1, 2017
Seth Crumpton
SupaFirefly Assignment
November 1, 2017

As you can see the DVH reveals a significant variation between the two plans. This is especially
true in the case of the heart and liver. The solid line of the SupaFirefly heart (brown) falls
approximately 20% lower along the 2000cGy line when compared to the dashed line of the
VMAT plan. A 7-8% difference can be viewed along the liver (gold) as well. Also, note that the
mean doses of each of the structures represent this significant variation as well. In the heart mean
dose we see a difference of 566.8cGy in favor of the SupaFirefly plan. In the liver we see a mean
dose difference of 379.1cGy in favor of the SupaFirefly plan.
In conclusion, I would say that the placement of the tumor would determine if the SupaFirefly
technique is the superior treatment option. In this case, I think it had its benefits and ultimately if
reducing cardiac dose or liver dose in this patient was a priority, SupaFirefly would be the
superior treatment option. This is especially important if you consider the emphasis by Palmer in,
Advances in Treatment Planning and Technologies for Esophagus Cancer to reduce cardiac
dose due to an increase in left ventrical ischemia in higher doses.1 I felt participation for in this
assignment was very beneficial and provides a foundation of learning that can be used when
critically assessing how to treat the esophagus effectively, while limiting cardiac dose as much as
possible. I would say that the planning objectives in the course content were not that helpful.
Comparing the SupaFirefly technique to a VMAT plan that had already been created at my
clinical site limited me on what structures I could add or get rid of. However, it was a good
reference to get the gist of what the planning objectives were and the priority they should have.
Listing the beam angles was obviously a huge help and when you actually apply them its simple
to see why it can be effectively used to limit dose to the heart and liver.
Seth Crumpton
SupaFirefly Assignment
November 1, 2017
wReferences:
1. Palmer M. Advances in Treatment Planning and Technologies for Esophagus Cancer.

AAMD. Accessed October 1, 2017.