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Brittany Bird
November 1, 2017

A Comparison of Treatment Approaches for Esophageal Cancer

There are a few varying approaches for the treatment of esophageal cancer including a
more traditional 3D conformal technique, intensity-modulated radiation therapy (IMRT), or
volumetric-modulated arc therapy (VMAT). In the presentation by Matt Palmer1, he discusses
implementing a step-and-shoot IMRT technique using a specific 6 MV photon beam
arrangement. The prescription is listed at 1.8 Gy for 28 fractions for a cumulative dose of 50.4
Gy. This approach is termed the SupaFirefly technique and has shown to demonstrate improved
results to the total lung, spinal cord, and heart dose. This SupaFirefly clinical approach will be
evaluated along with a popular VMAT planning technique to validate if this technique is truly
superior and produces an optimal treatment plan.
The SupaFirefly IMRT approach developed by Matt Palmer consists of a seven field
beam arrangement with angles of 60, 80, 120, 140, 160, 180, and 200. I altered the
photon energy from 6 MV to 10 MV and optimization objectives to follow the standard
techniques that my clinical facility uses. This will allow for both treatment plans to be compared
interchangeably. Palmers initial objectives that he used can be viewed in Table 1. These were
beneficial to use as a baseline starting point and allowed me to decide what critical structures
were of the highest priority. The treatment planning system (TPS) used for the assessment of the
two plans was Eclipse version 13.7 along with the Acuros calculation model. The VMAT plan
encompassed two full arcs with the clockwise beam (CW) rotating from 181 to 179, and the
counter-clockwise (CCW) beam rotating from 179 to 181. A collimator angle of 15 was
implemented for the CW beam and a collimator angle of 345 was used for the CCW beam to
reduce any interleaf leakage. VMAT is advantageous in that it can significantly reduce beam on
time and the length of time that the patient is on the table. Field data for each plan can be seen in
Figures 1 and 2.

Table 1. IMRT objectives and plan details for the SupaFirefly technique.
Structure Details Esophagus:8IMRT8Objectives
1 fsPTVexp15mm PTV,+,15mm Structure Objective Dose % Weight
2 fsring15mm fsPTVexp15mm,3,PTV PTV Min,Dose 5040 100
3 fsExternal Cover,slices,of,PTV,+/3,3,slices PTV Uniform,Dose 5140 100
4 fsNTavoid fsExternal,3,fsPTVexp15mm PTV Max,DVH 5325 0 100
fsring15mm Max,DVH 5040 2 5
Beam,Angles fsNTavoid Max,Dose 3500 100
1 0003060 fsNTavoid Max,DVH 2300 0 5
2 0003080 fsNTavoid Max,DVH 2000 4 5
3 0003120 Cord Max,DVH 4000 0 100
4 0003140 Total,Lung Max,DVH 500 # 10
5 0003160 Total,Lung Max,DVH 1000 # 10
6 0003180 Total,Lung Max,DVH 2000 # 10
7 0003200 Heart Max,DVH 3000 # 10
Heart Max,DVH 4000 # 10
Heart Max,DVH 5000 # 10

#,Reference,Estimator,IMRT:,Heart,and,Lung,Estimator
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Figure 1. VMAT field data for the treatment of esophageal cancer.

Figure 2. SupaFirefly field data for the treatment of esophageal cancer.

At my clinical facility, the majority of distal esophageal cancers are treated utilizing a
VMAT technique and following National Comprehensive Cancer Network (NCCN)
recommendations and specific Radiation Therapy Oncology Group (RTOG) constraints. Table 2
lists the optimization objectives and priorities used for both treatment planning techniques.

Table 2. Opitmization objectives used for both the SupaFirefly and VMAT treatment planning
techniques.
Structure Limit Vol [%] [cGy] Priority
Dose 104.5% upper 0 5340 200
Dose Ring upper 0 4900 200
External upper 0 5340 200
GTV/CTV45Gy upper 0 5340 200
GTV/CTV45Gy lower 100 5240 175
Heart upper 10 1000 150
Heart upper 0 5340 200
L Kidney upper 0 900 125
R Kidney upper 0 900 125
Spinal Cord upper 0 2500 100
Lung Total upper 45 100 150
Lung Total upper 20 800 150
Lung Total upper 0 5340 150

The dose-volume histogram (DVH) in Figure 3, compares the two treatment techniques
to each other. The square isodose lines represent the SupaFirefly technique, while the triangle
isodose lines represent the VMAT technique. There isnt a huge difference of maximum or
minimum mean dose for some of the structures between the two different techniques, with the
exception of the spinal cord, liver, and kidneys. The kidneys were spared slightly more with the
VMAT plan with a maximum dose difference between 300 to 400 cGy. The liver had a large
difference in minimum and mean dose, while the spinal cord varied in the maximum dose. The
liver received more low dose radiation in the VMAT plan and was covered more by the 20%
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isodose line. Coverage of the tumor volume is approximately the same, however, the VMAT
plan has a higher global maximum dose.

Figure 3. A DVH comparing the SupaFirefly and VMAT treatment techniques.

Table 2. Dose statistics for the SupaFirefly and VMAT treatment planning techniques.
Structure Plan Min Dose [cGy] Max Dose [cGy] Mean Dose
[cGy]
GTV/CTV45Gy SupaFirefly 4347.3 5380.2 5162.7
GTV/CTV45Gy VMAT 4599.5 5552.1 5205.4
Heart SupaFirefly 56.7 4461.8 499.3
Heart VMAT 70.1 4397.7 549.6
L Kidney SupaFirefly 21.5 1663.6 247.7
L Kidney VMAT 34.5 1223.6 255.7
R Kidney SupaFirefly 40.3 1525.1 316.7
R Kidney VMAT 36.1 1209.7 306.7
Spinal Cord SupaFirefly 0 3235.7 807.5
Spinal Cord VMAT 2.6 2764.5 776.1
Liver SupaFirefly 101.8 5270.0 1096.5
Liver VMAT 330.3 5320.0 1457.9
Lung Total SupaFirefly 14.4 5173.6 573.0
Lung Total VMAT 16.0 5186.7 550.0

After the final evaluation between each the SupaFirefly and VMAT treatment plans, I
dont believe either one is superior to one another as each plan had close to the same dose
statistics. If I didnt have to use the same objectives to compare the two, I could have probably
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pushed the structures in the VMAT plan harder in order to lower their doses even more. Overall,
I do like the SupaFirefly approach, as I didnt expect it to do such a great job sparing certain
structures and cover the tumor volume adequately.
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References

1. Palmer, M. Advances in Treatment Planning Techniques and Technologies for

Esophagus Cancer. [PowerPoint].