Spencer Day

DOS 773 Clinical Practicum III

September 13, 2021

VMAT vs. Supafirefly Comparison

This exercise encouraged students to compare two different treatment techniques for
esophageal cancer. These techniques included the primary technique used at the student’s
clinical site and a modified firefly technique dubbed the “SupaFirefly”. The primary esophageal
technique at my site is VMAT; therefore, my comparison will be between VMAT and the
SupaFirefly.
Requirements for this exercise included a prescribed total dose of 5040 centiGray (cGy)
given over 28 fractions for a daily fraction dose of 180 cGy. Normalization was set at 100% of
the dose to 95% of the target volume to keep the comparison equal. The VMAT planning
methodology was not restricted while the one requirement of the SupaFirefly plan was that the
beam geometry must be arranged as instructed. Students were given the option to follow
provided objectives and an estimator sheet, and although I gleaned ideas from the objectives
sheet, I did not follow it verbatim.
Structure Set
The patient utilized for this study had a stage IVb (T3, N1, M1) malignant neoplasm
within the middle thoracic esophagus. I repurposed the PTV for use in this comparison.
Contoured OARs were the lungs, heart, and spinal cord. The liver and other abdominal organs
were not contoured for a couple reasons. The first being the closest abdominal organ (liver) is
6cm away on the 4D average scan. The second is that the liver is a parallel organ, with the most
important parameter—mean dose—requires the whole liver to be contoured. The entire liver was
not included in this scan and thus the calculated mean would be inaccurate.
For both VMAT and SupaFirefly plans, I used an optimized PTV structure (PTV_Opti).
This structure was a duplicate of the original PTV (PTV_5040) with the bifurcation of the
trachea and primary bronchi excluded with no margin. This was to aid the optimizer in creating a
more homogenous distribution throughout the PTV volume. Optimization of PTV_5040 placed
hotspots within the airways which were not the target of the treatment.
A second optimized PTV (PTV+0.3) was retroactively implemented into the VMAT plan
due to severe hotspots appearing in the second-most superior and second-most inferior slices of
the PTV. This was most likely due to the tapering of the PTV in the sup-inf direction and the
NTO. The optimizer wanted to increase the scatter component to warm up the sup and inf ends
of the PTV. Since the NTO prohibited escalation of dose outside of the PTV, the optimizer tried
to create scatter within the PTV by warming up slices near the ends. PTV+0.3 alleviated this
issue by “fooling” the NTO into believing the PTV volume was larger in the sup-inf direction.
This structure was a copy of PTV_5040 but added a 0.3 cm margin in the sup-inf direction.
Further description of PTV+0.3 will be included in the VMAT optimization paragraph.
The last optimization structure added was fsNTavoid. This structure incorporated ideas
from the objectives Excel file, but with modification. PTV_5040 was expanded to a margin of 2
cm and cropped 0.15 cm away from PTV_5040. Essentially a ring or shell structure, fsNTavoid
was only used in the SupaFirefly plan.

Legend:

Red: PTV_5040

Larger Red Outline: PTV+0.3

Pink: Heart

Orange: Lungs

Green: Spinal Cord

Blue: Spinal Cord_PRV

Figure 1: Coronal View of the VMAT OAR, PTV, and Optimized Structures

Figure 2: Coronal View of the

Legend:
SupaFirefly OAR, PTV, and
Red: PTV_5040
Optimized Structures
Orange Surrounding PTV: fsNTavoid

Pink: Heart

Orange: Lungs

Green: Spinal Cord

Blue: Spinal Cord_PRV

Figure 3: Axial View of VMAT OAR, Legend:

PTV, and Optimized Structures
Note: The red contour excluding the airway Red: PTV_5040
is PTV_OPTI Red: PTV_OPTI

Pink: Heart

Orange: Lungs

Green: Spinal Cord

 Figure 4: Axial View of
Legend:
SupaFirefly OAR, PTV,
Red: PTV_5040
and Optimized Structures
Note:Red:
ThePTV_OPTI
red contour
excluding the airway is
The orange PTV: fsNTavoid
Orange Surrounding
PTV_OPTI.
structure
Pink:surrounding
Heart the
PTV is fsNTavoid.
Orange: Lungs

Green:
VMAT PlanSpinal Cord
Blue:
BeamSpinal Cord_PRV
geometry
consisted of 2 VMAT arcs
rotating between 181˚ and 179˚. Collimator angles were 15˚ for Arc 1 CW and 345˚ for Arc 2
CCW. Energy was set at 6X. The jaws were manually set to encompass the PTV throughout
rotation through the BEV (this was not necessary since I used jaw tracking, but I am in the habit
of it).

Figure 5: Machine Geometry for the VMAT Plan

Within the optimizer, I setup the following objectives as listed in Figure 6. To elaborate
on PTV+0.3, my first two iterations had hotspots close to the superior and inferior ends of the
PTV. To counteract the hotspots, PTV+0.3 was created and a lower objective was given to it
with a low dose and priority so that the NTO recognized this structure as a PTV. Subsequently,
this pushed the NTO farther out from PTV_OPTI in the sup-inf direction only and allowed the
optimizer to place just enough fluence on the outside to warm up the ends and mitigate some of
the hotspots.

Figure 6: Optimizer Objectives for the VMAT Plan.

Note: I cropped out the gEUD column as I did not use it and wanted to enlarge the table to help
with easier reading of the objectives.

SupaFirefly Plan
 The SupaFirefly plan was comprised of seven static field with gantry angles 60˚,80˚,
120˚, 140˚, 160˚, 180˚, and 200˚, in accordance with the requirements. Collimator angles were
then assigned to facilitate the best MLC geometry. Energy was set to 6X. I decided to implement
the static field IMRT optimizer in this plan to get the best fluence pattern possible with this
setup. Dynamic jaws were allowed in this plan and thus I did not preset the jaws.

Figure 7: Machine Geometry for the SupaFirefly Plan

Optimizing the plan utilized similar objectives except for PTV+0.3 being swapped out for
fsNTavoid (Figure 8). PTV+0.3 was not necessary in this plan as the hotspot distribution did not
concentrate near the ends. The fsNTavoid structure was utilized in place of the NTO function. In
my experience, NTO does not work as effectively in the static beam IMRT algorithms as it does
with VMAT, thus I implemented fsNTavoid as a ring structure to define falloff around the PTV.

Figure 8: Optimizer objectives for the SupFirefly Plan.

Note: I cropped out the gEUD column as I did not use it and wanted to enlarge the table to help
with easier reading of the objectives.

Table 1: Target and OAR structure dose objectives

Target Structure Objective VMAT SupaFirefly
PTV_5040 Maximum 53.92 Gy 54.62 Gy
Minimum 40.30 Gy 39.54 Gy
D95%>=100% 100% 100%
V100%>=95% 95% 95%
OAR Objective VMAT SupaFirefly
Total Lung V20<35% 5.7% 7.71%
Vmean<20Gy 7.17 Gy 6.74 Gy
V5<65% 48.3% 44.2%
Heart D(0.03cc) max<75 Gy 53.89 Gy 53.88 Gy
V50<25% 4.17% 4.00%
V30<50% 13.0% 11.2%
Mean<20Gy 12.57 Gy 11.45 Gy
Spinal Cord Dmax<=50Gy 27.94 Gy 31.07 Gy
 A

Figure 9: Axial views of the VMAT dose distribution (Letters in bottom right corner).
A) Superior of Isocenter B) Isocenter C) Inferior of Isocenter
Figure 10: Axial views of the SupaFirefly dose distribution (Letters in bottom right corner).
A) Superior of Isocenter B) Isocenter C) Inferior of Isocenter
Figure 11: DVH Comparison of the VMAT and SupaFirefly Plan
Note: Triangles indicate SupaFirefly, Squares signify VMAT

Questions
1. Was the outcome of the "SupaFirefly" Esophagus technique superior to methods used in
your clinic?

The SupaFirefly plan was at best equal to the VMAT plan traditionally used for
esophageal malignancies at my clinic. One benefit to this plan is that integral dose to the
body was less than the VMAT plan. This is due to the VMAT plan depositing dose
throughout its 720 degrees of rotation (2, 360˚ arcs). The SupaFirefly deposits dose
within only 7 static fields, which helps to minimize integral dose. Mean heart dose was
lower in the SupaFirefly plan yet lung dose was clinically insignificant and the VMAT
plan had a lower maximum dose to the spinal cord. One last noteworthy outcome was
that the VMAT plan had a lower percentage of hotspots over 105% in the PTV and a
lower significant maximum (0.03 cc).

2. How does this technique compare?

In terms of outcomes, VMAT and SupaFirefly were relatively equal, and I believe the
choice of which to implement is more reliant on clinical setup and individual cases.
VMAT would most likely be the primary technique because it is familiar and both plans
used the optimizer, therefore billing charges would be similar. SupaFirefly would be the
preferred method in cases where the patient would have their right arm down. Due to the
fact that it would be unfavorable to put entrance dose through the arm, SupaFirefly would
 avoid that geometry by entering through the left side. However, the big detriment to this
technique is that there are static field angles on both sides of the patient. This means the
200˚ field would have to be treated and then the machine spun around to 60˚ to continue
with the remaining fields. Time is wasted for the therapists when the machine could be
instead irradiating the tumor as it rotates (as with VMAT).

3. Was this arrangement helpful? Why or why not?

As stated in the previous questions, SupaFirefly excels when patient geometry is
unfavorable towards VMAT. Yet VMAT is familiar for most dosimetrists and the
SupaFirefly technique does not boast any clinically significant benefits when comparing
outcomes. SupaFirefly also has an awkward beam arrangement that wastes time waiting
for the machine to rotate to the other side. VMAT could emulate the angles of
SupaFirefly by placing avoidance sectors between 200˚and 60˚if need be or weight OAR
objectives so that the linac places less dose within that arc. However, VMAT still gives
the machine more angles to work with and can possibly find fluence patterns that better
spare OARs and still dose the PTV. Consequently, SupaFirefly is helpful in instances
where patient geometry favors that technique.