Jeanette Keil

DOS 793 Fieldwork III

9/12/2018
Esophagus SupaFirefly Technique Discussion
For our first planning assignment of the semester we were instructed to choose a
previously treated esophagus patient at our clinic and apply the SupaFirefly planning method and
compare the plans. Most of our esophageal patients have very long volumes and I was very
skeptical if this technique was going to produce a better plan. After viewing the presentation by
Matthew Palmer, I was ready to give this technique a try and was very surprised by the outcome.
The patient I chose was simulated using 4D CT to evaluate the motion of the target
volume and to help create a planning target volumes (PTV) that would account for any motion
from breathing during the treatment. The original plan was done using full arcs and normalized
100% covering 95% PTV. To test the SupaFirefly technique against the original volumetric
modulated arc radiotherapy (VMAT) plan, I decided to copy the optimization from the VMAT
plan, create a new plan with the suggested intensity modulated radiation therapy (IMRT) angles,
and re-run the plan optimization with the same constraints. I also used the same isocenter and
normalization for the new plan. Running the plan in this manner, I could already see a huge
difference. The SupaFirefly technique showed lower dose to the spinal cord, heart, liver, left
kidney, mean total lung, V10 lung, and V5 lung. The right kidney was a couple centigray (cGy)
higher and the V20 lung was 1% higher than the VMAT plan but I also did not push harder on
these structures because I wanted a true comparison by keeping the optimization and
normalization the same. I have attached a critical structure sheet showing the organs at risk
(OAR) limits and the values for each plan. I also noticed that the volume of the 105% isodose
line in the plan deceased significantly using this technique. The 105% isodose line for the
VMAT plan was 172.15cc compared to 0.53cc for the SupaFirefly plan.
Overall, I was very impressed by this technique and have been sharing it was all the
dosimetrists in my department. I have an esophageal patient I am currently working on for
treatment and I plan on using this technique and presenting the comparison to the physician. I do
not use IMRT very often but I think this will now be my go-to treatment planning style in the
future for esophageal patients after planning some comparisons to make sure that that technique
is suitable for most cases. I really enjoyed this project and was happy to learn a new technique
that I can add to my planning skill set.
 CRITICAL STRUCTURES ESOPHAGUS 5040cGy

OAR LIMIT (cGy) VMAT SupraFirefly

SPINAL CORD 4500 3425 3381

SPINAL CORD + 5mm 4800 3731 3608
HEART MEAN 3200 2011 1994
HEART 50% 4000 1747 1735
LIVER MEAN 2100 1560 1182
LIVER 30% 3000 1864 1298
COMBINED KIDNEY MAX PT 4500 3120 3329
RT KIDNEY 1/3 5000 561 671
RT KIDNEY 2/3 3000 160 172
RT KIDNEY 3/3 2300 66 74
LT KIDNEY 1/3 5000 237 177
LT KIDNEY 2/3 3000 117 87
LT KIDNEY 3/3 2300 50 36
MEAN DOSE TOTAL LUNG 2000 1102 1034
V20 TOTAL LUNG (%) 25 12 13
V10 TOTAL LUNG (%) 40 48 40
V5 BOTH LUNGS (%) 50 73 66

Volume of 105% (cc) 172.15 0.53