1

Jessica Ezelle

SupaFireFly Technique

November 1, 2017

Overall the SupaFireFly technique did not prove to be superior than the 2 arc VMAT plan
that I created in comparison. It was actually a lot more work and more time consuming to plan
the SupaFireFly technique than the VMAT plan. When I finished the SupaFireFly plan and saw
the statistics on the heart contour I was pleased with how low the V30, V40 and mean dose were
as suggested in Matthew Palmers presentation.1

Using the PTV created by the radiation oncologist for this patient, I began by creating the
structures asked of us on the ROI and constraints page. I then added those constraints and
weights into the optimizer. I then added all of the critical organs into the optimizer ensuring I
began both the SupaFireFly and VMAT plan with the same constraints and weights for each
organ. The original optimizer constraints were a combination of the radiation oncologists
planning directive, and two RTOG studies that followed the same prescription for organs in the
same general area. The RTOG 1010 for esophageal cancer was referenced and the RTOG 0848
for pancreatic cancer was also referenced.2,3 Both the SupaFireFly technique and the VMAT plan
were optimized with these constraints in Table 1 below and then tightened during the planning
process when it was seen that the dose to the critical structure could be reduced without losing
proper PTV coverage.

Table 1. Optimization constraints used to begin with.

ROI Type Gy Volume (%)
Total Lung Max DVH 5 60*
Max DVH 10 50*
Max DVH 20 30*
Max DVH 30 20
Heart Max DVH 30 50*
Max DVH 40 45
Max EUD 25*
Max Dose 52*
 2

Total Kidneys Max DVH 20 30*

Liver Max DVH 30 30
Max EUD 30
Spinal Cord Max Dose 40
Stomach Max Dose 56
*Denotes constraints derived from the radiation oncologist planning directive

Figure 1. The patients planning directive used for treatment.

Once both plans were complete to satisfaction their DVHs were used to compare the
critical organ dose volumes, mean doses and maximum doses, as well as to determine the
percentage of the PTV covered by the prescription dose. When compared, the SupaFireFly
technique does not contain any clinically significant dose differences to make it superior plan to
the VMAT plan. Almost all of the compared dose volumes, mean doses and maximum doses
were with 2 Gy if not less, with a few exceptions. The only difference in prescription between
the two was that the SupaFireFly prescription was prescribed to an ROI mean of the PTV and
 3

normalized to 97.8% to find a balance between proper PTV coverage and keeping critical
structures within their suggested tolerances. Whereas, the VMAT plan was prescribed to an ROI
mean of the PTV and normalized to 98.5%. This difference in normalization also allowed for a
significant difference in the amount of hot areas in the plans. The SupaFireFly had a maximum
hot spot of 54.36 Gy but there were areas of 105% and 107% seen throughout the CT. The
VMAT plan had a maximum hot spot of 53.83% and had very minimal areas of 105% showing
throughout the CT. It was much easier to achieve the lower areas of high dose with the VMAT
than the SupaFireFly technique. I believe this may be a product of the beams having 360, twice,
to get dose to the PTV whereas with the SupaFireFly all of the beams are basically coming from
the same area and multiple beams converge in the same area, causing a lot of dose to be
deposited in that area. The left posterior periphery of the SupaFireFly technique was hard to
cool off. There were areas of 95% and 90% dose found close to the surface of the body. I made
several attempts, including adding a larger ring, to limit dose out in this area. It did limit some of
the dose and it did rid the 100% dose that was originally in this area but I could not get rid of all
of the 95% and 90% dose areas.

Figure 2. All of the beams from the SupaFireFly plan and how multiple beams diverge into
multiple other beams.
 4

Figure 3. The 95% (the hot pink isodose line) and the 90% (the orange isodose line) spillage in
the left posterior periphery of the body in the SupaFireFly technique.
 5

Figure 4. The VMAT plan isodose lines showing the isodose lines from 70% and above tightly
hugging the PTV. A much more conformal isodose distribution. Only the 40% isodose line is out
in the periphery of the patient.
 6

Figure 5. SupaFireFly technique axial slices.

 7

Figure 6. The VMAT plan axial slices.

 8

Table 2. SupaFireFly Statistics vs. VMAT plan Statstics

Organ SupaFireFly Technique VMAT Plan
Kidneys
V20 0 Gy 0 Gy
Maximum Dose 18.02 Gy 16.95 Gy
Liver
V30 10 Gy 13 Gy
Mean Dose 13.08 Gy 15.62 Gy
Spinal Cord
Maximum Dose 32.38 Gy 32.36 Gy
Stomach
Maximum dose 54.68Gy 53.27 Gy20
Lungs
V5 38 Gy 39 Gy
V10 26 Gy 30 Gy
V20 14 Gy 12 Gy
V30 7 Gy 4 Gy
Mean Dose 7.84 Gy 7.48 Gy
Heart
V30 6 Gy 4 Gy
V40 2 Gy 2 Gy
Mean Dose 10.04 Gy 10.32 Gy
Maximum Dose 51.78 Gy 52.95 Gy
PTV Coverage 95% 96%
 9

Figure 7. The SupaFireFly DVH.

 10

Figure 8. The VMAT plan DVH.

Overall when comparing the ease of treatment planning, the table time being much
shorter, and no statistical differences in dose to the PTV or critical structures I would say that the
VMAT plan is the superior plan. The VMAT plan also limits all the extra 70% to 95% areas of
dose in the left posterior periphery of the patient where dose is not needed, therefore, advancing
the VMAT plan to a higher quality than the SupaFireFly plan. All of the critical structure
constraints proposed in Palmers presentation were obtained in the VMAT plan if not surpassed
by the VMAT plan. There is no need to add extra time to planning by complicating the planning
technique nor should the patient have to lie on the table longer when there is a technique
available that can help ease everyones lives.
 11

References

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

for Esophagus Cancer. [PowerPoint]. Huston, TX: The University of Texas MD Anderson
Cancer Center.
2. Safran H, Hong T, Haddock M, et. al. RTOG 1010 A phase II trial evaluating the addition of
trastuzumab to trimodality treatment of HER2-overexpressing esophageal adenocarcinoma.
NRG Oncology. 2016.
3. Abrams R, Regine W, Goodman K, et al. RTOG 0848 A phase II-R and a phase III trail
evaluating both *ERLOTINIB (PH II-R) and chemoradiation (PH III) as adjuvant treatment
for patients with resected head of pancreas adenocarcinoma. NRG Oncology. 2016.