Charity Rogstad

SupaFirefly Esophagus

October 31, 2017

At my clinical site most esophagus plans are done using a full arc VMAT technique. We
use a scorecard to evaluate our plans and we also put similar constraints in as our optimization
goals. For both the VMAT and SupaFirefly plan I used the same optimization constraints. You
can see below the initial optimization goals that were used.

After the initial optimization I drew in covers for each plan so that I would get 50.4Gy to
95% of the PTV volume. Along with covers I had a few hotspots that I wanted to be below 108%
or 54.43 Gy. I found it much easier to lower these hotspots with the VMAT plan then I did with
 the IMRT plan. I also normalized my prescription to 97% for my VMAT plan and 96.5% for my
SupaFirefly plan. The table below shows my scorecard goals and if it was met by each plan.
Both plans did fail in the max dose for the Small bowel, this is something we do our best to meet
but our physicians do not want to compromise coverage due to the small bowel (since it can
move from day to day and only a small amount is over the constraint). The last column does
show which plan achieved a better score for each goal and by how much.

ROI Goal Result Vmat Result SupaFly Difference

PTV 5040 50.4 Gy = 98% Volume 96% 95% Vmat - 1%
46.87 Gy = 99%
PTV 5040 Volume 100% 100% Equal
0% 0.4%
PTV 5040 53.93 Gy = 3% volume Max - 53.9Gy Max - 54.7Gy Equal
Left Kidney Mean 18-20 Gy 8.6Gy 12.1Gy Vmat - 3.5Gy
Left Kidney 12 Gy = <37% volume 24.40% 35.80% Vmat - 11.4%
Right Kidney Mean 18-20 Gy 2.6Gy 4.3Gy Vmat - 1.7Gy
Right Kidney 12 Gy = <37% volume 0.00% 4.40% Vmat - 4.4%
Combo Lung Mean 18Gy 8.9Gy 9.5Gy Vmat - 0.6Gy
Combo Lung 20 Gy = <30% volume 13.70% 17.90% Vmat - 4.2%
Combo Lung 50 Gy = <42% volume 1.00% 1.00% Equal
Heart Mean 22Gy 21.5Gy 20.4Gy SupaFirefly - 1.1Gy
0 0 SupaFireflyly -
Spinal Canal 45Gy = <0.1cc Max - 39.9Gy Max - 35 Gy 4.9Gy
Small Bowel 30Gy = <200cc 44.2cc 37.1cc SupaFirefly - 7.1cc
SupaFirefly -
Small Bowel 35Gy = <150cc 34.9cc 23.6cc 11.3cc
Small Bowel 45Gy = <20cc 5.3cc 5.5cc vmat - 0.2cc
0 1.8cc vmat - 1.8cc /
Small Bowel 54Gy = <0.1cc Max - 52.2 Gy Max - 54.3 Gy 2.1Gy
Liver 30Gy = <66% 9.40% 3.10% SupaFirefly - 6.3%
Liver Mean 40Gy 11.9Gy 11Gy SupaFirefly - 0.9Gy

When reviewing the above table the VMAT plan did better in 9 out of the 15 constraints
but if you take into account the amount of change which I have determined to be 5% or greater
(when looking at total volume or dose its also 5% of the total) the SupaFirefly plan outdid the
VMAT in 4 of the six areas. The SupaFirefly plan did better in areas of the heart, spinal canal,
small bowel and liver. The heart dose is found to be extremely important due to an increase in
left ventricle ischemia with higher doses.1
 Greater then 5%
ROI Goal difference
Left Kidney 12 Gy = <37% volume Vmat - 11.4%
Right Kidney Mean 18-20 Gy Vmat - 1.7Gy
Heart Mean 22Gy SupaFirefly - 1.1Gy

Spinal Canal 45Gy = <0.1cc SupaFirefly - 4.9Gy

Small Bowel 35Gy = <150cc SupaFirefly - 11.3cc
Liver 30Gy = <66% SupaFirefly - 6.3%

When looking at the axial images and reviewing the lower isodose lines the SupaFirefly
plan dose is less in the area of the heart but there also is increased dose in the left lung when
compared to the VMAT plan
 When comparing the coronal images below you can see that there is a drastic increase in
the amount of lung getting 25.2 Gy between the two plans.
 The sagittal images show the difference starting with the 40.3 Gy line. The VMAT plan
is more conformal while in the SupuFirefly plan the low doses arent as conformal.

I found this to be an interesting case and the information Matt Palmer presents is very
well done. I think location of the esophageal tumor plays a big role. For our next esophageal
patient I will present both options for the Physician to review.

Reference:

1. Palmer M. Advances in Treatment Planning and Technologies for Esophagus Cancer.

AAMD. Accessed October 1, 2017.