Esophageal Radiation Plan Comparison

Marina Cousins

Esophageal cancer is best treated by a multi-modality approach. Surgical resection is the

preferred method of treatment, but for unresectable or inoperable disease, chemo-radiation is
most effective, and radiation alone has a role in reducing severity or incidence of symptoms, and
in palliation.1

The typical esophageal prescription for curative intent is 50.4 Gy – 54 Gy in 1.8 or 2 Gy

fractions. Several planning techniques have been proposed over the decades, with advances in
technology utilized to provide better patient outcomes for what is a difficult area to treat.
Initially, and in palliative settings, a 3DCRT approach was used – but at curative doses, nearby
organs at risk received significant doses, leading to a range of side-effects. As IMRT became
more prevalent, various approaches to beam angle selection were investigated, all aimed at
reducing the dose to organs such as the heart, liver, kidneys and lungs. More recently, VMAT
has produced greater opportunity for conformity of the PTV and OAR sparing, but at the cost of
increased integral dose.

This paper compares the outcomes of two different planning techniques for the treatment of
esophageal cancer.

Planning technique: IMRT

Matthew Palmer (CMD) of MD Anderson proposed an IMRT beam template dubbed

“SupaFirefly” – a slight modification of other existing techniques, all named after flies.2
Specifically, his template called for 7 step-and-shoot fields at the following gantry angles:

Table of gantry angles for the SupaFirefly technique.

The study that he conducted at his institution demonstrated reductions in mean heart dose, mean
liver dose, and mean lung dose compared to techniques used previously.

Following his template, a plan was created and optimized as step-and-shoot IMRT using Ochsner
institute-specific goals and constraints for radiation treatment to the esophagus at 50.4 Gy in 28
fractions. The plan was normalized so that 100% of the dose covered 95% of the target volume,
as shown below.

Plan prescription and normalization.

The results of this plan were assessed using our institution-specific scorecard. Despite stringent
constraints, the plan achieved all required goals and constraints:

Scorecard results for IMRT esophagus plan: 50.4 Gy, 28#.

Planning technique: VMAT

For curative esophagus plans, our institution typically employs a VMAT technique. Generally,
VMAT produces plans where the higher isodoses conform more tightly to the PTV, thereby
reducing these dose levels to nearby organs at risk. This comes at the expense of a larger low-
dose region, which may not be appropriate for some patients (those with pacemakers, for
example).

For the same patient with esophageal cancer, a 2-arc VMAT plan was created and optimized
using the same objectives and constraints as the IMRT plan.

Table showing field details for the VMAT plan.

The plan was normalized in exactly the same way as the previous IMRT plan: 100% of the
prescription dose covering 95% volume of the PTV. All other parameters were also the same as
the IMRT plan – calculation grid size and algorithm, target volume and MLC margin, and total
prescription dose and fractionation.

Prescription and normalization of the VMAT plan.

As with the IMRT plan, the results of the optimization and calculation were assessed using our
institutional scorecard:
Scorecard results for VMAT esophagus plan: 50.4 Gy, 28#.

Plan evaluation and comparison:

One of the combined lung constraints for our institution is fairly stringent. We aim to reduce the
low dose bath to the lungs as much as possible, in order to reduce the occurrence of radiation-
induced pneumonitis. The VMAT plan struggled to meet this V5Gy < 60% combined lung
constraint – achieving a V5Gy of 60.2%. We know that increased spread of low dose is a feature
of VMAT planning, so this does not come as a surprise. This would be considered acceptable in
our clinic, as it is only just over the tolerance, and all other lung constraints are met. Since the
lungs are parallel organs, it is rare that we would compromise PTV coverage in a curative setting
in order to meet a constraint of this nature. The IMRT plan, however, met this constraint, in
addition to all others. Limiting the entry of the 7 IMRT beams to one side of the patient spares
more healthy tissue on the contralateral side. At first glance, when evaluating the scorecards,
IMRT appears to be the superior plan. The “SupaFirefly” technique claims to significantly
reduce mean doses to the lung, heart, and liver. In comparison to the VMAT plan, the mean dose
to the liver is reduced with step-and-shoot IMRT. The mean lung doses for both plans are very
similar, whereas the mean doses for the heart and combined kidneys is reduced in the VMAT
plan.

DVH showing doses to the combined lungs (purple), the liver (green), and heart (pink). There
are notable differences between the low doses each organ receives in each of the plans, but little
discernible difference in the high dose regions, where maximum dose constraints are set.

Most of the notable differences between the two plans are in how the dose is distributed
throughout the patient.
Side-by-side comparison of VMAT (left) and IMRT (right) techniques.

For the IMRT plan, on the right, the low dose isodose lines (30% Rx dose – pink) are constrained
to the left side of the patient, where the beams enter. In the VMAT plan, these isodose lines
extend out through most of the patient. This is where the IMRT plan is able to meet the V5Gy
<60% constraint for the lung far easier than the VMAT plan.

(Note: the green isodose line is displaying different normalized values on each plan, so visual
comparison for the 50%/40% isodoses cannot be made using this image.)

However, looking closely at the isodoses and dose distribution reveals that the savings in low
dose splash come at the cost of increasing areas of intermediate dose:
Dose distribution for VMAT plan (left) and IMRT plan (right).

It is clear to see that the cyan 70% isodose line is much more conformal in the VMAT plan.
There is no streaking or splash of intermediate dose in the VMAT plan, where this is evident in
the IMRT plan. Limiting dose entry to a particular segment of a patient reduces the ability of the
optimizer to converge on a solution for adequate target coverage without increasing the fluence
intensity in that area. A full VMAT arc provides the optimizer with a much greater range of
solutions. These ‘streaks’ of 70% Rx dose in the IMRT plan typically occur where the beams
overlap. When this happens, it is usually an indicator that the optimizer has had difficulty
respecting the goals, objectives and priorities input by the planner. Relaxing some of the
objectives within the optimizer may reduce some of these effects – particularly if there is room to
increase dose to OAR without exceeding the tolerance. For the IMRT plan in this instance, there
are even some areas of high-dose streaking. Doses greater than 70% Rx dose in the irradiated
volume, away from the PTV are discouraged. This is something we may expect to see within a
3DCRT plan, when beam modification options are limited by equipment, technology, or planner
skill – but less so in a technique that allows for direct modulation of the beam and fluence
intensity map.
Another depiction of low, intermediate, and high dose streaking within the IMRT plan (right).

The splash, or streaking, of intermediate dose throughout the patient can be better visualized in
the 3D model view of the patient.

3D distribution of the 50% isodose in both plans. Left plan, VMAT; right plan, IMRT.
Comparative DVH for both VMAT and IMRT plans.

Looking at the DVH, the most significant difference between the plans is that of intermediate
and low dose to the liver. This is not surprising since the static-field step-and-shoot IMRT plan
reduces beam entry through the right side of the patient, where the liver is located.

Conclusion:

The superiority of one plan over another really depends upon the desired objective. The
“SupaFirefly” technique does reduce dose to organs – but primarily at the low dose level, and in
parallel organs. It does this by compromising conformity of dose around the PTV, and can result
in higher dose streaking or splash if the plan is not optimized in an appropriate way, or if the plan
constraints are too stringent.

Using current optimization algorithms, IMRT is often faster to plan than VMAT, because of the
reduced number of solutions possible. IMRT does, however, result in increased treatment
delivery time, depending upon the complexity and number of arcs within the VMAT plan.

In facilities with VMAT capability, this planning technique is usually utilized more often, with
physicians and dosimetrists understanding the resultant trade-off between conformity and size of
the irradiated volume. VMAT typically allows for dose escalation, although in esophageal
irradiation, studies have demonstrated that doses beyond 50.4 – 54 Gy are not any more effective
with regards to local control.

This “SupaFirefly” technique may have been an overall improvement over other IMRT
solutions, and 3DCRT plans, but is now primarily more suited to instances where low dose
irradiation is a concern – such as with pacemakers and other implanted devices, or pre-existing
comorbidities that result in reduced organ function and would benefit from as much dose-sparing
as possible.