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SupaFirefly vs VMAT plan comparison

Esophageal cancer accounts for only 1% of all the cancers diagnosed in the US and it is 4 times more common among men
than women. Cancer of the esophagus usually starts in the mucosa and grows outwards towards the submucosa and the muscle layer.
Depending on the type of involved cells, the esophageal cancer is divided into 2 categories: Squamous cell or Adenocarcinoma.1 Local
treatment for this type of cancer involves surgery, chemotherapy or radiation therapy and many times a combination of the latter.
Radiation treatment could be used before surgery to shrink the tumor or after surgery to kill any microscopic residue of the
cancer cells. It also can be used with chemo to make the radiation treatment more effective or if the patient cannot undergo surgery for
any specific reasons. There are different external beam radiation techniques that can be used to plan and treat esophageal cases such as
3D, IMRT and VMAT. Nonetheless of what technique is chosen for treatment, there is the concern of sparing the organs at risk such
as the heart, lungs, liver, spine, and depending on the tumor expansion possibly the kidneys and bowel. Uncountable efforts have been
done to come up with the best way to treat the tumor while maximizing the sparing of the organs at risk. Along the years dosimetrist
and physicists have proposed different techniques to achieve this goal. Matthew Palmer CMD proposed a beam arrangement technique
to be used with IMRT, called the SupaFirefly technique. He proposed the usage of 7 photon beams with specific angles of 60, 80,
120, 140, 160, 180, and 200, with the purpose of lowering the cardiac dose.2
For the purpose of this assignment a plan comparison between a VMAT plan and the SupaFirefly technique was created. In
order to create a fair comparison, prescription, energy, objectives, and constraints used for evaluation were kept the same for both
plans. The prescription was 28fx at 1.8Gy/day= 50.4Gy for both plans using 10MV. Total lung-CTV was the only one pseudo
structure created for optimization and constraints purposes. A total of 2 rings were used in both plans to control dose spillage to
normal tissue passed the PTV. A 0.5cm ring around the PTV was created to control 95% of the dose tight around the target and a
second ring to control 80% of the dose to stay about 2cm from the treatment volume. Both plans were normalized to the 100% and
they were both analyzed using the constraints from the treatment directives used in the Northwell Health system.3
Hard Constraints Prioritized goals
PTV D95>95% D95>100%
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Lung Mean<20Gy, V20<35%, V5<65% V20<20%, V5<55%, V40<10%
Spine Dmax<45Gy
Kidneys D60<20Gy(for at least 1 kidney)
D30<18Gy(if both kidney functioning)
D10<18Gy(if 1 kidney)
Heart D30<50Gy
Liver Mean dose<30Gy

When comparing the results from both plans site to site it is notable how the isodose lines are more conformal in the VMAT
plan compared to the Supafirefly technique. The 70% (cyan) and 50% (orange) isodose line is tighter around the target. These results
were expected since the Supafirefy beam arrangement is using static IMRT which the isodose lines profile often dont result as
conformal as the ones obtained from VMAT.
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Although not significant, the overall plan for the Supafirefly technique resulted hotter (max dose of 108.5%) than the VMAT
plan (max dose of 105.5%).
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The DVH comparison between the two plans shows that the PTV coverage is relatively the same for both. However, the dose for the
Heart and Liver has significantly reduced in the SupaFirefly technique. The heart D30 for the VMAT was about 30Gy and for the
SupaFirefly was about 24Gy. Even though both plans meet the D30<50Gy constraint for the heart, the SupaFirefly technique achieved
a lower exposure to the heart.
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SupaFirefly VMAT
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The liver also received an overall lower dose in the SupaFirefly technique and the right kidney. These results are achievable
since the beams for the SupaFirefly are mostly kept on the left side of the body and the organs located on the right side, such as the
liver and right kidney will most likely receive only exit dose.

The SupaFirefly method is a good technique to employ for minimizing dose to the heart, liver and even the kidneys. When
compared to the most common method used in my clinic for esophageal treatment, VMAT, the SupaFirefly technique shows better
sparing of the organs at risk but worse dose conformity around the target, in this case resulting in a slightly higher total lung dose. I
believe this technique could be very useful for cases where some of the organs constraints cannot be met using arcs and static IMRT is
needed.
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References:
1. Radiation Therapy for Esophageal Cancer. American Cancer Society. https://www.cancer.org/cancer/esophagus-
cancer/treating/radiation.html. Accessed October 30, 2017.
2. Palmer M. Advances in Treatment Planning Techniques and Technologies for Esophageal Cancer. [PowerPoint]. Houston,
TX: The University of Texas MD Anderson Cancer Center.