Ryan Salem

SupaFireFly Technique Plan Comparison

Due: 9.19.18
In my clinic, esophagus treatments are generally done with the utilization of VMAT, as esophageal treatment
volumes tend to be rather circular and central in the body. Below shows the PTVEsophagus and the Esophagus
in the plan I re-created using the SupaFireFly technique. The PTV included the lower 2/3s of the esophagus and
a margin of 1cm around it.

In treatments of the upper thorax, a number of OAR constraints are followed in my clinic. In this case, these
were the constraints of utmost importance: Heart V45 < 67%, V40 < 100%, Mean Heart Dose < 26Gy, Lung
V20 < 37%, Mean Lung Dose < 20Gy, Spinal Cord + 3mm < 45Gy, Bowel Max Dose < 50Gy, Liver V35 <
50%, and Liver V30 < 100%. Other bowel constraints and kidney constraints are recognized, but these
structures were kept well below the tolerance so I did not evaluate them in this comparison.
Below, the top shows the original VMAT plan utilizing 2 full arcs and collimator angles of 15 and 345 degrees.
The plan was normalized so that 98% isodose was delivered to 100% of the PTVEsophagus with a maximum
hot spot of 108.1 and mean coverage of 103.5. Given the round and central nature of the esophagus in the body,
VMAT was a very effective method of treatment and all coverage and OAR constraint goals were well met. The
GE junction was included in the PTV, so the stomach constraints, V50 < 2%, V45 < 25%, and Max Dose <
5400Gy, were not followed in this case. The stomach outside of the PTV was addressed so that minimum dose
was delivered here, however. In the bottom image is the recreated plan using the SupaFireFly technique.
Original VMAT plan

Replicated plan with the SupaFireFly technique.

The SupaFireFly was able to make a very similar plan with 90% isodose and above. Again, the plan was
normalized so that 98% isodose was given to 100% of the PTVEsophagus with a maximum hot spot of 108.5%
and mean coverage of 104.2%. Although both plans are very comparable, the SupaFireFly technique posed an
advantage when comparing the overall heart dose. The mean dose on the heart was over 6% less with the
SupaFireFly technique and the maximum hot spot in the lungs was decreased by 2.3%. Additionally, the mean
dose of the liver was lowered by 1.6%. These advantages came with the cost of increasing the
Spinal_Cord_3mm mean dose by 6.6% and the maximum dose by 28.2%. Visually, it easy to see that the low
isodose lines like 50% and 25% deliver dose to much more regular tissue with the Static IMRT beam
arrangement.
As the lecture discussed, this technique can come in handy when trying to keep the mean heart and mean lung
doses low. In this case, the mean heart dose was certainly kept lower, and the lung was only different by a
negligible amount. If heart toxicity is of utmost concern, I can certainly see the use of this unique technique
clinically. The SupaFireFly did give a lot of extra dose to the small bowel and spinal cord though, both of which
are fairly radiosensitive OARs with considerably low constraints: Bowel Max < 50Gy, Spinal Cord Max <
45Gy. If the patient is likely to return with a spine met or abdominal tumor, this technique could give dose to
critical organs and make future planning much tougher.
Below is a composite DVH as well as a comparison of OAR constraints and target coverage goals on a
ClearCheck table. The  represents the original VMAT plan, and the Δ represent the SupaFireFly plan.
SupaFireFly ll VMAT