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Bianca Tester
September 18, 2018

A Comparison of Treatment Techniques for Esophageal Cancer

Before computed tomography (CT) simulation existed, esophageal cancer was

traditionally localized by the patient drinking oral contrast and the use of a fluoroscopic
simulator, and was treated with anteroposterior-posteroanterior (AP/PA) fields to 36-41 Gy,
followed by oblique fields for the boost.1 With all of the advances in not only imaging, but also
the capabilities of the treatment machines, there are now more options to treat esophageal cancer,
including intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy
(VMAT). The focus of this paper is to compare Matt Palmer’s modified “SupaFirefly”
technique2 to a 3D conformal arc plan (the technique most used to treat esophageal cancer at my
clinical site) to see which plan was more optimal and had less dose to normal OAR. Depending
on the location of the tumor (proximal vs distal) there will be several critical structures to try
limiting dose to, including the heart, liver, lungs, spinal cord, and stomach.
For Matt Palmer’s technique, he used an IMRT step-and-shoot with 7 gantry angles (60°,
80°, 120°, 140°, 160°, 180°, and 200° – his angles are the same orientation as my plan described
below). The patient had a prescription of 1.8 Gy/day for 28 fractions, for a total dose of 50.4 Gy.
To keep an accurate comparison, both Matt’s plan and mine used the same patient, data set
information, and both plans were normalized to 97%.
For my conformal arc plan, the arcs were technically 2 half arcs with “fly wedges.” For
the first arc, the gantry was at 175° and rotated up to 0° (0° is considered the AP and 175° is
posterior, on the right side of the patient) and the collimator was set to 5°. I used a 30° hard
wedge with the heel positioned on the left side of the patient, and the toe right side. Then, for the
second arc, the gantry rotated from 0°, down the patient’s left side, to 185° with the collimator
still set to 5°, and the wedge was positioned heel on the patient’s left side, toe on the right side,
and a 15° wedge was used.
When comparing the SupaFirefly technique to the 3D conformal arc, both plans are fairly
comparable, however the SupaFireFly technique was slightly better with the dose to the heart,
liver, lungs and stomach. The one constraint that stuck out the most to me was the dose to the
spinal cord. This is the one major area where the 3D conformal plan produced significantly less
dose compared to the SupaFireFly. The purpose of the SupaFireFly technique is to help lower
the dose to the heart and lungs, which it did achieve (and it did produce less dose than the
conformal arc plan). Keeping that in mind, I didn’t like how much dose the spinal cord received.
In my own personal opinion, when looking at the DVH comparison between the two plans
(shown below: SupaFireFly in solid, conformal arc in dashed), I would have chosen my plan for
treatment.
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To me, the slight difference in the dose to the lungs, stomach, etc. didn’t give me enough reason
to want to accept such a high spinal cord dose (since the dose with the conformal plan is still
well below the accepted tolerances). The QUANTEC3 max dose for the spinal cord is 45 Gy,
and the SupaFireFly technique gave the spinal cord a max dose of 41.2 Gy while my conformal
arc plan only gave 26.9 Gy. Knowing that esophageal cancer is very difficult to treat, and has a
high likelihood to recur, I don’t feel comfortable giving that much dose to the spinal cord when
the patient might need to come back for more radiation. If this patient specifically had heart or
lung problems then I would be more inclined to use Matt Palmer’s plan.
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Below is an example of a side-by-side comparison between Matt’s plan (shown on the left) and
mine (on the right). As you can see from the isodose lines in the transverse image, although
Matt’s plan has less of the 1008 cGy overall, he has an isodose line of 3528 cGy dosing the
spinal cord, versus mine being missed even by the 2520 cGy isodose line.

Shown below is a coronal view, again, with Matt’s plan on the left and mine on the right. Matt’s
plan is slightly more conformal and his plan does have slightly better PTV coverage as well,
however the comparisons were so close I felt the spinal cord dose was the deciding factor for me.
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References
1. Yang G, McClosky S, Khushalani N. Principles of modern radiation techniques for
esophageal and gastroesophageal junction cancer. Gastrointest Cancer Res. 2009 Mar-
Apr; 3(2 Suppl 1): S6-S10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684733/
2. Palmer, M. Advancement in treatment planning techniques and technologies for
esophagus cancer. [PowerPoint lecture]. MD Anderson cancer center. La Crosse, WI:
UW-L Medical Dosimetry Program; 2017.
3. Bentzen S, Constine L, Deasy J, et al. Quantitative analyses of normal tissue effects in
the clinic (QUANTEC): An introduction to the scientific issues. Int J Radiat Oncol Biol
Phys. 2010 Mar 1; 76(3 Suppl): S3-S9. doi: 10.1016/j.ijrobp.2009.09.040.