Jenna Cimmiyotti

Clinical Practicum III

September 11, 2021

IMRT “SupaFirefly” Esophagus Plan Comparison

For this assignment, I generated 2 treatment plans using different planning techniques.
The first plan (Plan A) utilized a VMAT technique, which is commonly used at my clinical site,
and the second plan (Plan B) used the SupaFirefly technique. Each plan was prescribed a total
dose of 50.4 Gy delivering 1.8 Gy/day over 28 fractions. Both plans were normalized so that
95% of the planning target volume received 100% of the prescription dose. Although it is not
common practice to normalize at my clinical site, this allowed for more direct comparison when
evaluating the two plans.
In preparation to start the planning process, I evaluated the shape and size of the target
structure as well as its proximity to organs at risk (figure 2). I created optimization structures that
were used for both treatment plans (figures 3-5). First, I created a dose limiting annulus (DLA)
structure to help control the dose outside of the PTV. The DLA structure is created by expanding
the PTV by 3 cm and then cropping it away from the PTV by 0.2 cm (figure 1). Next, I created
optimization structures for the organs at risk that overlapped with the PTV volume including the
heart, small bowel, and stomach. For the inside optimization structures, I used the boolean tool to
create a structure consisting of the overlapping region of the OAR and PTV. The outside
optimization structures are created by cropping the OAR away from the PTV by 2 mm. The
inside optimization structures are useful in limiting hot spots from falling within a particular
OAR. Whereas I use the outside optimization structures to drive the dose outside of the PTV as
low as reasonably achievable.
Figure 1: DLA optimization structure (yellow), PTV (magenta)

Figure 2: Digitally reconstructed radiograph with PTV (magenta) and organs at risk including
the large bowel (gray), small bowel (orange), cord (cyan), heart (red), left kidney (yellow), right
kidney (cyan), liver (brown), left lung (yellow), and right lung (light green).

Figure 3: Stomach optimization structures; stomach outside (green), stomach inside (blue), PTV
(magenta)
Figure 4: Small bowel optimization structures; SB outside (orange), SB inside (cyan), PTV
(magenta)

Figure 5: Heart optimization structures; heart outside (red), heart inside (yellow), PTV
(magenta)

Field Arrangement:
Plan A/VMAT plan:
I chose to complete the volumetric modulated arc therapy plan using 3 arc rotations with
a 6 MV beam energy. The gantry rotated from 181 degrees to 179 degrees in the clockwise and
counterclockwise directions. The collimator angles for arcs 1, 2, and 3 was set to 5°, 355°, and
90°, respectively (figure 6). The collimators were selected to minimize leakage between the
multileaf collimators as well as conform the dose around the irregularly shaped target.

Figure 6: Field arrangement for VMAT plan.

Plan B/Static IMRT plan using the SupaFirefly Technique:

For the second treatment plan, I created a static IMRT plan using the SupaFirefly
technique as described in Matt Palmer’s presentation. The SupaFirefly technique utilizes the
following gantry angles: 60°, 80°, 120°, 140°, 160°, 180°, and 200° (figure 7). All fields had a
collimator angle of 0°. Of note, the specific gantry angles used in this technique are concentrated
on the left and posterior side of the patient. When I was reading about this technique, I quickly
recognized this would help to spare the anterior and right sided normal tissues such as the small
bowel, large bowel, right kidney, and portions of the stomach.

Figure 7: Field arrangement for Static IMRT plan using SupaFirefly technique.

Optimization
Both plans were optimized using the Eclipse version 15.1.51 photon optimizer. I
optimized both plans using the same optimization structures described previously. Figure 8
demonstrates the optimization objectives used. I started optimizing by placing an upper and
lower objective on my PTV as well as an upper objective on the DLA structure. Once I had
achieved adequate coverage on the target, I also placed objectives on the OAR. The final step
was to normalize each plan so that 95% of the target received 100% of the prescription dose.
Figure 9 displays the planning objectives and achieved doses for each plan.
Figure 8: Optimization objectives used for planning.
Figure 9: Planning Objectives and achieved doses for each plan.
VMAT – 6 MV SupaFirefly – 6MV
3 full arc rotations Static IMRT
Constraint VMAT result SupaFirefly Result
PTV V100% ≥ 95% 95% 95%
V95% ≥ 99% 99.9% 99.9%
D1% ≤ 110% 105.2% 102.8%
CTV V100% > 99% 99.7% 99.2%
Lung_total Mean < 15 Gy 7.97 Gy 8.20 Gy
V5 Gy < 60% 41.9% 42.9%
V13 Gy < 30% 21.4% 18.6%
V20 Gy < 20% 10.2% 11.9%
Cord Max < 45 Gy 30.46 Gy 39.43 Gy
V45 Gy < 0.1% 0% 0%
Heart Mean < 26 Gy 15.11 Gy 14.37 Gy
V25 Gy < 50% 18.7% 16.6%
V30 Gy report 13.2% 13.0%
V40 Gy < 30% 7.3% 8.4%
V50 Gy < 20% 2.9% 3.4%
Liver Mean < 25 Gy 17.51 Gy 12.74 Gy
V30 Gy < 60% 8.2% 6.4%
CV30 Gy > 700 cc 1258.17 cc 1283.57 cc
Kidney_total Mean < 18 Gy 5.97 Gy 6.62 Gy
V12 < 55% 14.7% 22.1%
V20 Gy < 60% 1.3% 1.5%
Kidney_L V6 Gy report 39.1% 33.0%
V18 Gy < 10% 3.2% 3.5%
Kidney_R V6 Gy report 41.7% 52.7%
V18 Gy < 10% 2.7% 2.2%
Stomach Max report 53.27 Gy 52.13 Gy
V30 Gy report 67.8% 61.5%
V45 Gy report 55.8% 56.0%
V50 Gy report 53.4% 54.3%
Bowel_small Max report 51.65 Gy 51.82 Gy
Mean report 30.06 Gy 30.13 Gy
V15 Gy report 67.58 cc 67.94 cc
V52 Gy < 0.03 cc 0 cc 0 cc
Bowel_large Max report 50.55 Gy 51.51 Gy
Mean report 24.91 Gy 25.8 Gy
V45 Gy report 0.5% 0.5%
V50 Gy report 0% 0%
V60 Gy report 0% 0%
Figure 10: Axial images of the VMAT plan (left) and SupaFirefly plan (right)
Figure 11: Plan comparison DVH
 Questions:
• 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?

After reviewing the DVH, achieved dose metrics on the planning template, and
performing a visual side-by-side comparison, the 2 treatment plans were very comparable. Both
plans met all the planning objectives taken from a gastrointestinal planning template used at my
clinical site. The liver had a drastic decrease in mean dose on the SupaFirefly plan as seen on the
DVH. This is due to the characteristic beam arrangement of the SupaFirefly technique. Unlike
the VMAT plan, none of the static IMRT beams entered through the liver. It would be
advantageous to use the SupaFirefly beam arrangement if the patient had previous liver
irradiation. However, I was able to achieve a lower maximum dose on the spinal cord on the
VMAT plan compared to static IMRT plan. Perhaps the posterior beam of the SupaFirefly
technique could be adjusted slightly to be positioned off the spinal cord. However, both plans
kept the maximum spinal cord dose under the required 45 Gy constraint. Both plans were able to
spare the kidneys sufficiently with the V18Gy ranging from 2.2%-3.5%. Additionally, the V30
Gy, V40 Gy, V50 Gy and mean dose to the heart was similar on both plans. Overall, the dose
distribution on the VMAT plan was more conformal with a tradeoff of having more integral dose
than the static IMRT plan. The SupaFirefly technique was superior in sparing the liver, although
resulted in streaks of higher doses from the static beams.
Although both plans would be considered acceptable at my clinical site, the vast majority
of these patients would be treated with a proton plan. Due to the nature of the proton beam, there
are advantages in sparing more normal tissue compared to a photon plan. The standard beam
angles that are used for a proton esophagus plan at my clinical site is 2 posterior oblique beams.
This aids in sparing of the OAR in the anterior abdomen such as the heart, small bowel, large
bowel, and stomach (figure 12).
Overall, I found this assignment to be a beneficial in learning a new technique to add to
my knowledge base. Static IMRT is not often utilized at my clinical site therefore it was a great
opportunity to practice that technique. Clinical cases may often require the planning dosimetrist
to be creative and adapt to various patient specific circumstances. By learning a variety of
planning techniques, I will be more prepared to troubleshoot a difficult plan in the clinical
setting.

Figure 12: Dose distribution of a proton plan utilizing 2 posterior oblique beams.