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Bijoy Anand

SupaFireFly Technique

November 1, 2017

SupaFireFly (SFF) is a technique developed at MD Anderson (Houston, TX) for treating

esophageal cancer. It utilizes certain selected beam angles - from 60 to 200 - in order to lower
dose to critical organs. In his presentation, the author, Matthew Palmer1 reports decreases in total
lung mean dose (TLMD) by 38 cGy, heart mean dose (HMD) by 209 cGy and liver mean dose
by 252 cGy.

For this project, I selected a patient who was treated with a prescription identical to the
one given in the assignment: 50.4 Gy in 28 fractions (Fx), 180 cGy/Fx. Original plan that was
used for treating the patient was a 7-field IMRT plan, same number of fields as the SFF plan but
different angles. Both plans used 6 MV photon beams. The beam angles are shown in figure 1
below for visual comparison. Table 1 shows the numerical detail.

Figure 1. Beam arrangement comparison: SupaFireFly plan vs. original plan

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Table 1. Beam angles (in degrees) for the two plans

Original 15 95 150 180 210 265 345

SFF 60 80 120 140 160 180 200

The optimization objectives for planning were taken from the following goal sheet that is
followed in our clinic. Planning was done on RayStation treatment planning system (TPS).

Figure 2. Optimization objectives used for Esophagus planning

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The isodose lines showing coverage to the planning target volume (PTV) at isocenter in
the transverse, sagittal, and coronal planes are presented in figure 3a. The deep red line is 100%
isodose line (5040 cGy), and the hot pink line is 95% (4788 cGy).

Figure 3a. Isodose lines in 3-view for SupaFireFly plan

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The corresponding 3-view of isodose lines for the original plan is shown in figure 3b.
[Please note that the original plan was made in March 2017 when we were still using Pinnacle.
So, I am unable to show a side-by-side comparison image ] The bright green shaded area is
PTV, the yellow area is CTV and the red area is GTV.

Figure 3b. Isodose lines in 3-view for the original plan

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Was the outcome of the implementation of the "SupaFirefly" Esophagus technique superior?

By simple visual inspection, one can easily tell that the SFF plan has more conformal
lines, a tighter coverage. Scrolling through the slices I verified that this was the case throughout
the volume. A more thorough and definitive comparison of the two plans can be made using
dose-volume histogram (DVH). This will be presented next in figures 4a and 4b, followed by a
discussion of the results.

Figure 4a. DVH for the SupaFireFly plan

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Figure 4b. DVH for the original plan

We can see that both plans met the target coverage goals. SFF plan was overall cooler
plan max dose 108.2% versus 112.5%. This is probably because for the original plan the
optimizer was pushed harder to achieve lower total lung dose. The original plan has better
numbers for V5, V10, V20, V25, and V35: 47.2%, 28.7%, 17.2%, 12.1%, and 6.2% respectively.
The corresponding values for SFF plan are: 67.6%, 39.4%, 18.8%, 15.3%, and 6.5%.

The mean heart dose is better for SFF plan: 24.2 Gy, as opposed to 25.6 Gy for the
original plan. This translates to a reduction of ~ 120 cGy, less than what Palmers article
mentioned, but still significant. Similarly, the mean liver dose is better for the SFF plan: 10.7 Gy
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versus 13.3Gy, a reduction of ~ 260 cGy. Finally, spinal cord dose (at 0.1 cc) also shows a
substantial reduction: 41.0 Gy compared to 47.5 Gy ~ 650 cGy.

In summary, I would have to conclude that implementing the SFF technique led to a
superior plan: more conformal, overall cooler, and lesser dose to critical organs except for the
lung dose. The comparison is a bit harder to make because the original plan was optimized on a
different TPS (Pinnacle) and by a different planner.

Was it helpful? Were the planning objectives helpful? Why or why not?

Yes. In terms of planning, making the SFF plan was easy because all the details were
provided. The beam angles were given, how to make all the false structures for optimization
were described, even the weights were provided! The only numbers I could not find were the
percentages for total lung and heart constraint. I actually emailed Matt Palmer for his Heart and
Lung Estimator, but did not hear back So, I used the planning objectives taken from the
esophagus protocol we use in our clinic.

It is hard for me to make a comparison against the original plan in terms of ease of
planning and the time needed simply because it was done by another planner on another TPS.

Side notes:

I calculated the uninvolved heart volume (94.4%) which is very similar to Palmers example
(92.0%). The other parameter distance from PTV border to Carina (DPC) was 0.0 cm in this
patients case as the PTV overlapped the carina. Using these, I compared my results against his
correlation study.

1. It is interesting that my data point for %UIH vs. HMD falls slightly higher than the
reoptimized data (and closer to the original data) on the graph presented by Palmer. See slide #29

2. The TLMD value for my SFF plan is 12.1 Gy which is again higher than his reoptimized line
and closer to the original data value of 12 Gy.
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References

1. Palmer M. Advances in Treatment Planning Techniques and Technologies and Techniques

for Esophagus Cancer. [PowerPoint presentation]. Houston, TX: The University of Texas MD
Anderson Cancer Center, 2010.