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At the University of Rochester Medical Center, the most common way to treat an
esophagus patient would be to use beam arrangements that are similar to the SupaFireFly
technique; however, the factors that decide this would be the positioning/shape of the PTV
volume and the stylistic method of each Medical Dosimetrist. Static intensity modulated
radiation therapy (IMRT) is rarely used at my clinic because volumetric modulated radiation
therapy (VMAT) tends to deliver the treatment quicker, and with better conformity. Due to the
regulations put forth at the University of Rochester, all plans that involve lung within the treated
field requires only the use of lower energy (6x) and the use of the Acuros External Beam
algorithm for increased accuracy of the lung/tissue gradient changes. The patient that I chose for
this project has an integrated boost, meaning there were 2 volumes treated to different doses. The
PTV_1 volume received a total dose of 50.4, while the PTV_2 received a dose of 45 Gy.

Figure 1. PTV volume is shown in green.

The length of the total PTV is roughly 25 cm, and spans almost the entire length of the
lungs. Due to the position of this volume, and multiple attempts using strictly VMAT and Static
IMRT, it was decided to use a hybrid technique of oblique fields with 2 full VMAT arcs.
Typically, hybrid techniques involve AP/PA fields that help to lower lung dose, and then either
VMAT or DCA (dynamic conformal arcs) are used to help shape the dose. Using a true AP/PA
field on this patient was not feasible in this situation since the esophagus sits above the spinal
cord, and the PA field would give too high of a dose to the spinal cord, and the AP field would
be going straight through the heart. To avoid this issue, the fields are angled just enough to spare
some of the spinal cord and heart, knowing we are sacrificing some of the lung volume. The
more the gantry is angled off of 0 and 180, the more lung tissue will be involved in the
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treatment. With this plan, we had to find a balance between lowering the heart and spine dose,
while keeping the lung dose as low as possible.

Figure 2. (Left) Axial view of RAO and LPO opposed fields. RAO has a gantry angle of 334.
LPO has a gantry angle of 154. (Right) 3D view of RAO field, green structure depicts the PTV.

At my clinical site, it is a standard practice to use 2 full arcs for VMAT planning, unless
partial arcs are required to avoid certain structures. Due to the length of the volume to be treated,
partial arcs would not be beneficial due to critical structures that fully surround the PTV volume.
The main objectives for this plan were to try and reduce the lung dose as much as possible, along
with the heart, liver, and spinal dose.

The SupaFireFly technique utilizes 7 gantry angles, most of them coming from the
posterior and left lateral portion of the patient. This technique is used to reduce dose to the liver
and heart, and dose to the left lung, if possible.1

Figure 3. SupaFireFly beam angles.

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For this plan, I assessed each gantry angle, and for fields 1, 2 and 3, and I decided to
collimate the field to avoid the spinal cord. I felt this was necessary because the esophagus sits
anterior to the spinal cord, and given the length of the PTV, if there was a way to limit dose to
the spinal cord, then it should be done. Fields 4, 5, 6, and 7 had a collimator angle of 0. I did not
feel it would have any benefit by turning the collimator.

Figure 4. Fields 1, 2, and 3 showing collimator angles of 345, 338, and 345 respectively. The
PTV is shown in green, Heart is salmon, lungs are pink, kidneys are purple, liver is dark blue,
small bowel is orange.
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Figure 5. Fields 4, 5, 6 and 7, all showing no collimator rotation.

After comparing both plans, I feel that they both have their pros and cons, but overall, the
statistics showed comparable results, with some notable exceptions. Both plans came to be about
5% hot, which is reasonable. For the hybrid technique, 100% of the volume received 97% of the
prescription dose. And for the SupaFireFly technique, 100% of the volume received 95.2% of the
prescription dose. The SupaFireFly technique was superior in its ability to limit dose to the liver
(mean dose only) and the kidneys. It makes sense that the liver dose would be low in the
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SupaFireFly technique since the liver is only receiving exit dose. Because most of the beam
angles went through the posterior portion of the patient, I was expecting the spinal dose to be
high, but it actually ended up being 8.3 Gy less on the SupaFireFly plan. I attribute this to the
fact that there are 7 beam angles being used, so the dose is able to be spread out. Putting a beam
right through the spine is something I felt uncomfortable doing when I first started my clinical
rotation. But I was told by Nathan Jones, CMD, that sometimes the easiest way to get around
something, is to go through it. This statement holds true for the SupaFireFly technique.

DVH Statistics

Hybrid SupaFireFly
(triangles) (squares)
Lung V20 33.7% 35.3%
Heart (Mean) 26.1 Gy 26.1 Gy
Liver (Mean) 19.5 Gy 16.1 Gy
Kidneys (Mean) 8.5 Gy 9.1 Gy
Spinal Cord (Max) 39.9 Gy 31.6 Gy

The hybrid technique was able to yield a slightly lower V20 lung dose. Both plans had a
higher V20, but considering the target volume and its position within the chest, this is to be
expected. The main issue with the SupaFireFly technique was my inability to get the hotspot
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within the PTV. The hotspot occurred in a small triangular area between the lung, spine, and
PTV. Rings were used on both plans, but the rings were not successful in the SupaFireFly plan to
limit prescription dose to surrounding tissue. The hotspot also ended up just 2 centimeters from
the spinal cord, and with daily setup error and patient movement, I do not feel comfortable with
that.

Patients Dose Intent

Hybrid SupaFireFly

Liver 60% getting 30 Gy 11.7% 12.1%

Liver 25 Gy Mean 19.1 Gy 16.1 Gy
Kidney 70% receiving 20Gy 2.4 Gy 2.3 Gy
Heart 100% less than 30Gy 4.9 Gy 7.4 Gy
Lung V20 33.7% 35.3%
Spinal cord 45Gy Max 39.9 Gy 31.6 Gy

Figure 6. (Left) Hot spot location on hybrid plan and (Right) hot spot on SupaFireFly plan.

I found this discussion very interesting because when I planned my first esophagus
patient at my clinical site, I used a beam configuration that was typically used at the site I
worked at as a Radiation Therapist. This configuration consisted of 3 beams: an AP, an RPO,
and LPO field. After planning this patient, and reviewing the plan with my preceptor, Neil Joyce,
CMD, he told me that at the University of Rochester, we do not enter through the heart when
designing esophagus plans. He provided me with the literature that included Palmers
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SupaFireFly technique. I have been developing plans with beam arrangements similar to the
SupaFireFly technique ever since that conversation. I find it interesting how different facilities
will utilize completely different planning techniques.
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References

1. Palmer M. Advancement in Treatment Planning Techniques and Technologies for

Esophagus Cancer. [PowerPoint]. MD Anderson Cancer Center.