Amber Mehr

Minneapolis VA
Esophagus SupaFirefly

Prompt: Was the outcome of the "SupaFirefly" Esophagus technique superior than methods used
in your clinic? How does this technique compare? Was this arrangement helpful? Why or why
not?

At the Minneapolis VA, the medical dosimetrists use an 8-field intensity modulated
radiation therapy (IMRT) plan setup to treat esophageal cancer. The beams are arranged to avoid
the contralateral lung. The arrangement of the beams for this case was a 160º left posterior
oblique (LPO) beam, a 120º LPO beam, an 80º left anterior oblique (LAO) beam, a 40º LAO
beam, a 0º anterior beam, a 320º right anterior oblique (RAO) beam, 240º right posterior oblique
beam (RPO) and a 200º RPO beam (Figure 1). This technique maintained coverage while
meeting organ at risk (OAR) constraints.

The SupaFirefly esophagus technique was introduced as an alternative method for

treating esophageal cancers. The goal of this planning technique was to avoid dose to cardiac
structures.¹ For this treatment 7 IMRT beams were arranged as a 60º LAO beam, an 80º LAO
beam, a 120º LPO beam, a 140º LPO beam, a 160º LPO beam, 180º posterior beam, and 200º
RPO beam (Figure 2).¹ This arrangement was also able to maintain coverage and meet OAR
constraints.

The two techniques are very comparable when looking at the planning target volume
(PTV) coverage and hot spots. For the 8-Field IMRT plan, 100% of the dose covered 98.84% of
the PTV when normalized to 95%. The hot spot was 56.97 Gy within the PTV. For the
SupaFirefly technique, 100% of the dose covered 96.39% of the PTV when normalized to 95%.
The hot spot was 56.43 Gy within the PTV. The coverage for the 8-field IMRT plan was better
than the SupaFirefly but the hot spot for the SupaFirefly plan was slightly lower than the 8-field
plan.

One of the biggest differences between the two planning techniques was the isodose
distribution. The isodose distribution for the 8-field IMRT plan had a more conformal
distribution as well as more dose anteriorly within the patient (Figure 3). The plan was more
conformal due having more beams while dose ran more anteriorly because of the anterior beam
placement. The isodose distribution for the SupaFirefly technique was less conformal and had
higher dose posteriorly near the skin surface (Figure 4). Treatment conformality and lower
surface dose was harder to achieve using this planning technique due to the number of beams
located posteriorly and the beam spacing. The higher patient surface dose was noticeable when
observing the isodose distributions of both plans as well as when comparing the maximum skin
dose. The 8-field IMRT plan had a maximum skin dose of 34.97 Gy while the SupaFirefly plan
had a maximum skin dose of 43.18 Gy.

Another major difference in the two planning techniques was the dose they contributed to
OAR. The 8-field IMRT plan had higher spinal cord, heart, and liver dose than the SupaFirefly
technique (Table 1 & Figure 5).² This made sense because the SupaFirefly technique’s main goal
is to spare the heart.1 The 8-field IMRT plan however, had lower dose to the kidneys and lungs
(Table 1 & Figure 5).² The beam placement for this was a major contributor because the
SupaFirefly technique was focused mainly on placing beams posteriorly and on the left side of
the patient. This led to more dose within the left kidney and left lung when compared to the 8-
field IMRT plan.

When deciding which technique to use, the medical dosimetrist must consider what the
physician is looking for. If the physician is wanting to limit dose anteriorly as well as spare dose
to the heart, spinal cord and liver, the SupaFirefly method would be the better approach. If the
physician wants to have a more conformal dose distribution and limit dose to the left lateral side
of the patient, using a beam arrangement like the 8-field IMRT treatment planning technique
would get them nicer results. Both planning techniques make nice treatment plans for patients
because they both meet all the OAR constraints as well as obtain PTV coverage. Learning this
new SupaFirefly arrangement is helpful because it is a great alternative approach to treating the
esophagus with critical organ sparing.
 References
1. Wang J, Palmer M, Bilton SD, et al. Comparing proton beam to intensity modulated
radiation therapy planning in esophageal cancer. Int J Particle Ther. 2015;1(4): 866-877.
https://doi.org/10.14338/IJPT-14-00018.1
2. Bradley J, Choy H, Komaki R, et al. RTOG 0617: A randomized phase III comparison of
standard-dose (60 Gy) versus high dose (74 Gy) conformal radiotherapy with concurrent
and consolidation carboplatin/paclitaxel +/- cetuximab (IND #103444) in patients with
stage IIIA/IIIB non-small cell lung cancer. Lancet Oncol. 2015(2):187-
199. https://dx.doi.org/10.1016/S1470-2045(14)71207-0 
 Tables & Figures

Figure 1. Beam placement for 8-Field IMRT treatment plan

Figure 2. Beam placement for SupaFirefly treatment plan
Figure 3. Isodose distribution for 8-Field IMRT treatment plan
Figure 4. Isodose distribution for SupaFirefly treatment plan
Table 1. Organ at risk constraints and the comparison of the 8-field IMRT and SupaFirefly plans²
Organ at Risk Constraints 8-Field IMRT SupaFirefly
Spinal Cord Max Dose (Direct) ≤ 45 Gy 38.62 Gy 28.50 Gy
Lung V20 ≤ 32% V20 = 18.19% V20 = 19.14%
(total lung vol – PTV) Mean Dose ≤ 20 Gy Mean dose = 9.81 Gy Mean dose = 10.55 Gy
Heart V60 < 33% V60 = 0.00% V60 = 0.00%
V45 < 66% V45 = 13.88% V45 = 9.88%
V40 < 100% V40 = 19.11% V40 = 12.76%
Liver Mean dose < 25 Gy Mean dose = 16.44 Gy Mean dose = 13.21 Gy

Kidney V18 < 10% (both kidneys) V18 = 3.96% V18 = 6.85%
V18 < 50% (left kidney) V18 = 7.89% V18 = 13.65%
V18 < 50% (right kidney) V18 = 0.00% V18 = 0.00%

Figure 5. Dose volume histogram comparing dose to critical organs for the 8-Field IMRT plan
(dashed) and SupaFirefly (Solid)