Esophagus Plan Comparison Continued:

PLAN 2

Optimization Structures

The optimization structures created for Plan 1 were used for Plan 2. I created two more control
structures called ‘NS_Avoid_02a and NS_Avoid_02b’(Fig 7a and Fig 7b) By using the Region
of Interest (ROI) to define the extent of these structures, I cropped the body structure (or
external), 2mm from PTV_4140 and PTV_5040 respectively. I put an upper constraint on these
structures at level 3 of my optimization to prevent stray high dose outside of the PTV_4140 and
PTV_5040. I am able to reduce stray high doses for static field IMRT plans with these control
structures (NS_Avoid_02a and NS_Avoid_2b).

Fig7a: Showing body cropped 2mm from PTV_4140 Fig7b: Showing body cropped 2mm from PTV_5040

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Plan Parameters

I used the same plan parameters for both Phase 1 and Phase 2

Energy: 6MV

Gantry Angles: I used the suggested gantry angles for the SupaFirefly technique: 60°, 80°, 120°,
140°, 160°, 180°, 200° (Fig 8). I set my isocenter at the geometric center of the PTV. I used the
same gantry and collimator arrangements for the phase 1 and phase 2 plans.

Fig 8: Showing beam arrangement for Plan 2

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Calculation Algorithm: Anisotropic Analytical Algorithm (AAA) version 15.6.06

Calculation Grid: 0.25cm

Table 3: Showing field parameters for phase 1 plan for plan 2

Table 3: Showing field parameters for phase 2 plan for plan 2

I started this plan with an objective to have 100% of dose to the PTV with a priority of 150. For
the OARs, I started with a priority of 85%. I put in the minimum dose constraint requirement for
the OARs but made sure I started off with good target coverage. During optimization, I changed
the priorities and objectives for the targets and OARs as needed by increasing priority for hard to
meet constraints and minimizing less to meet constraints. For both plans, I set my NTO priority

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to 100, distance from target border to 0.3cm, Start-dose to 100%, end dose to 60% and fall off t0
0.15. I ran this plan a couple of times to get what I wanted.

After my plan optimization and I renormalized each plan (Phase 1 and Phase 2) to have 95 % of
each PTV receiving 100 % of the prescription dose. I then converted the 110% isodose line into
structure and dose painted it to reduce the hotspot. I then formed a composite of Phase 1 and
Phase 2 plans to a total of 5040 cGy.

Isodose Distribution of composite plan (Plan 2)

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5
DVH of Plan 2

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Dose Constraint Comparison

ORGAN *GOALS ACHIEVED (PLAN 1) ACHIEVED (PLAN 2)

ARCS SUPAFIREFLY
Lungs V40 < 10 % 1.5 % 1.3 %
V30 <15 % 4.5 % 3.6 %
V20 < 20 % 13 % 10 %
V10 < 40 % 36 % 31 %
V5 < 50 % 62 % 55 %
Mean < 20 Gy 9.7 Gy 8.6 Gy
Spinal Max < 45 Gy 25.4 Gy 35.2 Gy
Cord
Bowel Max < PTV Max 46.6 Gy ( PTV Max = 5405 44 Gy (PTVMax=5315.3
D5 < 45 Gy cGy) cGy
31.4 Gy 29 Gy
Heart V30 < 30 % 21 % 20 %
Mean < 30 Gy 22.6 Gy 21.8 Gy
Kidney, V18 < 33 % Lt Kidney: 16 % Lt Kidney: 11 %
each Mean < 18 Gy Rt Kidney: 5.3 % Rt Kidney: 4 %
Lt Kidney Mean: 6.1 Gy Lt Kidney Mean: 5.6 Gy
Rt Kidney Mean: 6.2 Gy Rt Kidney Mean: 5 Gy
Liver V20 < 30 % 18 % 16 %
V30 < 20 % 10 % 8%
Mean < 25 Gy 12.6 Gy 11.6 Gy
Stomach Max < 54 Gy 53.2 Gy 52.4 Gy

* Requested dose constraint goals are from NCCN 2.2019

Discussion

The dose constraint outcome of the “SupaFirefly” Esophagus technique is slightly superior than
the two-arc technique plan. However, I do not think the difference in the achieved dose
constraints are significant. The “Supafirefly” technique resulted in less integral dose than in the
two-arc technique, hence, producing a better dose sparing to parallel organs like the lungs and
kidneys.
Also, the “Supafirefly” technique produced a total of 2249 MUs compared to a total of 916 MUs
from the two-arc plan. Patients treated with the “Supafirefly” technique will spend twice as much
time on-beam than with the two-arc plan. A longer on-beam time is likely to result in patient
motion during treatment. The actual received dose to organs at risk from treatment could be

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significantly different from the achieved dose from the plan when there is a significant patient
motion during treatment.
The ‘Supafirefly” technique was helpful and is definitely a choice technique in situations where
VMAT treatment is not available. The “Supafirefly” technique could also produce very
significant difference in dose to the lungs for mid-esophageal cancers.