Esophagus SupaFirefly Technique

As most of us know, there are many different ways to plan a radiation treatment course.
This is particularly the case as it pertains to esophageal plans. For this exercise, I compared the
esophagus “SupaFirefly” technique with a two arc VMAT esophagus plan. The results I found
were interesting.

My thought going into this exercise was that the VMAT plan would simply be better than
the SupaFirefly one. VMAT creates conformal plans and tends to be the “go-to technique” for
dosimetrists here at my clinical site. Below are axial images of both plans. It can be plainly seen
that the VMAT plan is indeed more conformal than the SupaFirefly one. However it can also be
noted, by observing the data in the top right corner, that the hot spot for the SupaFirefly plan is
lower than the VMAT plan.

Transverse Image – VMAT Plan

Transverse Image – SupaFirefly Plan

The next variable I checked was the PTV coverage and OAR doses of the two plans.
These can be seen in the dose volume histograms (DVH) below. Both plans were normalized so
that 100% of the prescription dose covered 95% of the PTV. This resulted in identical coverage
between the two plans. The triangle line is the SupFirefly plan where the square line refers to the
VMAT plan.
 The OAR constraints between the two plans had noticeable differences as well. With the
square line being the SupaFirefly plan and the triangle line being the VMAT plan, the difference
in spinal cord dose can be observed. The SupaFirefly plan has a higher spinal cord mean and
max dose. This makes sense given the proximity of the target volume to the spinal cord. That,
combined with the fact that many of the SupaFirefly beams pass directly through the spinal cord,
leads to a higher dose. All of this being said, the spinal cord still passed the max dose constraint
of 4500 cGy for both plans.

Spinal Cord Doses – Both Plans

There was also a noticeable difference in the total lung dose between the two plans. The
SupaFirefly plan had a lower mean and max dose compared to the VMAT plan. This, again,
makes sense due to the beam arrangements used. The SupaFirefly technique treats the volume
almost entirely from one side. This limits the dose to the opposite lung.
Total Lung Doses – Both Plans

All in all, I believe the two methods are very similar. Each has different positives and
negatives that would have to be weighed by the dosimetrist and physician. Both plans provided
sufficient coverage of the PTV and met all of the dose constraints for the OARs. However, in the
end, I believe that I would still choose the VMAT plan. Given that both plans are so close, I
would defer to the patient experience. With a static seven field IMRT plan, the patient is going to
be on the table longer than a two arc VMAT plan. It’s not much, but it is something to consider.

Dose Constraints – Both plans met these constraints

Organ Volume Volume Limit Max Limit

Liver 60% 30 Gy
Liver 25 Gy (mean)
Heart 100% 30 Gy
Heart 50% 40 Gy
Lung 20% 30 Gy
Lung 40% 10 Gy
Spinal Cord 45 Gy