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Michael S Wheatley
Clinical Practicum III
Supafirefly vs VMAT Esophagus Plan Comparison

For the esophagus comparison study, I found a previously treated esophageal case and using the
project guidelines, replanned the case using Volumetric Modulated Arc Therapy (VMAT) and
the Supafirefly step & shoot Intensity Modulated Radiation Therapy (IMRT) technique. I
evaluated each of the two plans using QUANTEC dose constraints provided in the Mobius chart,
which is commonly used in my clinic in lieu of any specific physician provided constraints.

Case Study: patient is a 66-year-old gentleman with diagnosis of squamous cell carcinoma
(SCC) of the distal esophagus. Staging was presented as T3NxM0. Patient otherwise healthy
with a Karnosky status of 90. Patient was simulated supine with arms above head resting on a
wingboard. Knees were flexed with a large bolster. Three mm slices were acquired to
encompass the entire anatomy from base of skull through pelvic crests. The original treatment
prescription was 4140 cGy in 23 fractions at 180 cGy per fraction.

For each new plan the prescription was for the primary target volume (PTV) to receive 5040 cGy
in 28 fractions at 180 cGy per fraction. The PTV is to be normalized so that 95% of the PTV
will receive 100% of the prescription dose.

Contoured structures included: PTV_5040, GTV, CTV, heart, Left Lung, Right Lung,
esophagus, spinal cord, and liver. I then created heart-PTV+.3, liver-PTV+.3, esphagus-PTV+.3
(to be used for uninvolved esophagus), total lung, total lung-PTV, total lung-PTV+.3, spinal cord
PRV(.5) and Ring90% (2,-0.3 margins from PTV).

For the first plan I used a VMAT planning technique. This technique is the common standard of
care at my clinic for esophageal cancers. I decided upon the use of two full arcs using 6X.
Using the Planning Geometry Tool, I came up with optimal collimator angles and jaw sizes to
best conform to the PTV volume.
Planning Parameters
Field Energy Gantry Collimator Couch X1 X2 Y1 Y2
Arc 1 6X 181-179 30 0 7.8 7.8 8.5 8.5
cw
Arc 2 6X 179-181 330 0 7.8 7.8 8.5 8.5
ccw
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Once in Optimization, I set the primary target with upper and lower limits. I like to allow for
100% to receive prescription dose and 0% to be at 105%. In this case I set the 0% at 5292 cGy.
I used a 90% ring to receive 4788 to better conform the dose to target and spare normal tissues.
For the other structures I set the following objectives –

Once satisfied that all OAR would be acceptable for the dose constraints and target coverage met
prescription, I calculated the plan and normalized so that 95% PTV_5040 would receive the
prescription dose of 5040 cGy.

Next, I planned the same case using the Supafirefly static IMRT technique. This was interesting
as I had never done static IMRT planning before. The physicists and dosimetrists had to assist
for this one and even they had to remember back years on how to set it up. I believe my clinic
only did static IMRT for a very brief time before the use of Rapid Arc came into practice.

I used all the same contours and optimization structures from the VMAT plan. Fields were
created based on the technique’s standard gantry arrangement.
Planning Parameters
Field Energy Gantry Collimator Couch X1 X2 Y1 Y2
1-60 6X 60 0 0 6.0 6.5 9.3 6.0
2-80 6X 80 0 0 6.4 5.6 9.3 6.0
3-120 6X 120 0 0 9.8 3.5 9.0 6.0
4-140 6X 140 0 0 10.8 3.4 8.8 6.3
5-160 6X 160 0 0 10.7 3.8 8.8 6.0
6-180 6X 180 0 0 9.0 4.3 8.5 6.3
7-200 6X 200 0 0 7.5 4.7 8.5 6.3
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Once in Optimization, I used the saved template from the VMAT plan and found that only minor
little deviations were needed to achieve the desired optimization results. I did find this
interesting that the two different beam arrangements would yield almost the same optimization
objectives. The following were used for the step&shoot plan –

Following optimization, I calculated the plan and normalized so that 95% of PTV_5040 would
receive 100% of the prescription dose of 5040 cGy.

After completion of both plans, I evaluated the targets and OAR using the QUANTEC dose
constraints for conventional fractination contained in the Mobius 3D chart. The following were
the results of the major contoured OAR –
STRUCTURE SUPAFIREFLY VMAT
Heart - Mean 1677.3 cGy 1676.7 cGy
- 33% < 60 Gy 1828.9 cGy 1806.2 cGy
- 67% < 45 Gy 1091.9 cGy 1117.5 cGy
Lung Left – Mean < 20 Gy 1249.4 cGy 1127.2 cGy
V20 < 37% 25.8% 18.9%
Lung Right – Mean < 20 Gy 690.8 cGy 928.7 cGy
V20 < 37% 5.4% 6.7%
Lung Total- PTV – Mean 885.2 cGy 963.1 cGy
< 20 GY
V20 < 37% 13.4% 11.0%
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Uninvolved Esophagus – 1693.8 cGy 1650.0 cGy

Mean < 35 Gy

- 15% < 54 Gy 5240.5 cGy 5209.8 cGy

- 33% < 45 Gy 814.9 cGy 835.2 cGy
Spinal Cord Max < 45 Gy 2975.2 cGy 2353.0 cGy
Liver – 50% < 35 Gy 812.9 cGy 1599.0 cGy
Max Dose < 115% 109.3 % 110.5%
PTV_5040 95% getting 5040 cGy 95% getting 5040 cGy
GTV 100% getting 5013.6 cGy 100% getting 4991.3 cGy

Based on DVH evaluation alone, I believe that the standard VMAT plan provided better dose
constraints for the OAR. The two structures that the Supafirefly technique improved upon were
the right sided structures of Liver and Right lung. That should be expected as the VMAT plan
used 2 full arcs depositing dose more around the right side of the patient where in the Supafirefly
technique most of the beam angles were directed to the left side.
Plan evaluation showing 100%, 90% and 80%isodose coverage between the two plans –

VMAT Supafirefly
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Looking at the isodose lines, the VMAT plan had a much more conformal distribution as you can
see the yellow 90% line hugs the PTV volume where in the Supafirefly technique it was slightly
less conformal.
Plan evaluation showing 50% isodose cloud –

VMAT Supafirefly
Looking at the 50% isodose cloud, it looks like the VMAT plan provided far better normal tissue
sparing as the supafirefly technique had many more 50% fingers and not near as conformal as the
VMAT plan.
Plan evaluation showing all isodose lines –
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DVH plan comparisons of Targets and Lungs –

DVH plan comparisons of Targets, Heart, Liver, Spinal cord, Uninvolved Esophagus –
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Was the outcome of the “Supafirefly” Esophagus technique superior than methods used in
your clinic?
Based on DVH and isodose coverage evaluations, I would recommend the VMAT plan still be
the standard of care for this patient’s case. In a case where we may have difficulty meeting total
lung Mean and V20, this could be adapted as it did help to spare the right lung quite a bit more
and still provides acceptable but higher doses for the other OAR.

How does this technique compare?

As seen in the previous evaluations, the VMAT plan provided for an overall better plan as far as
isodose coverage, conformity, and decreased dose to OAR near the target volume.

Was this arrangement helpful? Why or why not?

I don’t believe this arrangement would have been helpful in this patient’s case. I do believe that
it would have been far superior to a 3-field technique that is also sometimes used in my clinic.
For me personally it was a good opportunity to be able and plan a static field IMRT step&shoot
plan. These types of plans are not implemented in my clinic currently.