Makelle Barski

September 18, 2019

DOS 773- Clinical Practicum III

Esophagus Comparison Plan

The clinic that I am currently at typically uses volumetric modulated arc therapy (VMAT) when treating
esophageal cancer. It is standard to use two full arcs to achieve a more conformal plan. Recent news in
our clinic is that one of our machines with VMAT is going down for awhile, leaving us with only one
machine with VMAT capabilities. Our patient load is quite high, so it is going to be encouraged to plan
IMRT as much as possible on the machine without VMAT capabilities. IMRT is beneficial in events like
these or even when insurance will not cover VMAT. When planning an IMRT esophageal cancer case, the
“SupraFirefly” technique can be used to produce a desirable plan.

The prescription was 28 fractions at 1.8 Gy a day making the total dose 50.4 Gy. Both plans were
normalized to make the prescription dose cover 95% of the PTV. The isocenter was placed by the
physician at approximately the center of the anticipated PTV at the time of simulation. The energy used
throughout both plans were 6 MV. The technique used for IMRT calls for 7 beams at specific gantry
angles. The gantry angles are at 60°, 80°, 120°, 140°, 160°, 180°, and 200°. The technique used for VMAT
was 2 full arcs. One clockwise arc going from 181°-177° with a collimator rotation of 10°. The other arc
went counterclockwise from 179°-183° with a collimator rotation of 350°. The collimator rotations were
present to reduce MLC leakage.

The target dose in my clinic is at least 95% of the volume receiving 100% of the dose. The hotspot is to
be under 110%. The planning objectives for my plan are as follows:

I rarely do IMRT cases and mainly do VMAT, so I was surprised to see that the outcomes of the two plans
were very similar. Both plans met all planning objectives as shown in the scorecards below:
IMRT Scorecard

VMAT Scorecard

The scorecard indicates that coverage was similar at about 95% (when we normalize on pinnacle we
adjust the monitor units so in this case it is not exactly 95% but the closest it can get to it). Both plans
stayed under 110% and had minimal 105%. Please refer to the scorecards above. I was surprised to see
that,, for the most part, the IMRT regions of interest (ROI) were slightly better than VMATs. The
exception here were both kidneys and the spinal cord. This is due to there being more low dose
posteriorly. More differences can be seen when looking at the isodose lines:

IMRT ISODOSE

When evaluating the isodose lines, we can see that the “SupaFirefly” has more cold spots within the PTV
than the VMAT plan. After my first optimization, I had around 98% coverage and it did not have the cold
spots. It was definitely a plan we would use in clinic. The cold spots are not preferable after normalizing
the coverage to 95%, but it is acceptable. We should also note that there is also more low-dose bath
posteriorly, yielding a higher dose to the kidneys and cord.

VMAT ISODOSE

When looking at the VMAT plan, we can see that the PTV coverage is more uniform and does not have
as many cold spots. The VMAT plan has slightly less 105% in the PTV. Overall, the VMAT looks more
conformal, however it seems to have more low dose bath anteriorly and laterally.
Trial Side by Side: VMAT (left) vs. IMRT (right)

DVH Comparison
Another way to evaluate these plans are by looking at the dose volume histogram (DVH). Similar to what
we can see on the scorecard and isodose lines, the PTV is relatively the same. ROIs in the IMRT plan are
receiving a slightly lower dose than the VMAT plan, with the exception of the kidneys and more volume
is receiving higher dose in the cord.

Overall, the plans were very similar and they each have their own advantages and disadvantages. VMAT
was more conformal and uniform. There was more low-dose bath when using VMAT. Another
disadvantage for VMAT is that QA is more extensive. IMRT had less low-dose bath and had more
planning objectives that met better. A disadvantage to IMRT is that it may take longer to treat the
patient which may cause more patient motion or set-up errors. The plans are very comparable, and it
would be the physician’s preference as to which plan to use. Our physician does not like to see cold
spots in the PTV so VMAT would be the choice here. However, because IMRT has a similar outcome
using the “SupraFirefly” technique, this approach could be utilized if VMAT is not an option or if you
want to reduce dose to certain ROIs.