1

Alecia Eliason
Esophagus Supafirefly Technique
Clinical Practicum III
October 30, 2017
3D vs. Supafirefly Planning for Distal Esophageal Radiation Therapy
Although rates of esophageal cancer in the United States have remained relatively stable
for years1, the necessity for high-quality and innovative radiation therapy treatment plans
continues to be imperative, and much research has been done to identify best techniques.
Esophageal cancers requiring definitive radiation therapy are typically prescribed 50.4 Gy at 1.8
Gy per fraction.2 This can be delivered via various techniques, including 3-Dimensional (3D),
Intensity Modulated Radiotherapy (IMRT), Volumetric Modulated Arc Therapy (VMAT), or
helical radiation therapy. A frequently employed 3D technique involves AP-PA fields with the
addition of oblique and/or lateral fields to avoid the spinal cord. Often times, however, these
supplementary fields increase the dose to the lung and possibly the heart. Consequently, a study
performed by Nutting et al3 compared 3D planning to that of IMRT to determine if lung dose
reduction is improved with IMRT planning. Researchers found that a 9-field IMRT had good
target coverage and homogeneity but did not improve lung dose, while a 4-field IMRT plan did
lower the mean lung dose. With heart dose still an issue, an optimal IMRT planning technique
referred to as the Supafirefly technique, utilizing 6 gantry angle-specific beams, was developed
to decrease both lung and heart doses when treating esophageal cancers.4 In this discussion I will
compare a typical 3D esophageal treatment plan created at my clinical internship site to that of
the Supafirefly technique to evaluate benefits and drawbacks of each.
At my clinical internship site, Froedtert and Medical College of Wisconsin, 3D
esophageal plans are commonplace. Often, instead of using the historic AP-PA fields, only one
of the two will be used in order to lessen the spinal cord dose, and one or two additional oblique
fields are added to improve conformality. For this particular patient, a dose of 50.4 Gy at 1.8 Gy
per fraction covering 95% of the PTV was prescribed. PTV and organs at risk constraints as
dictated by the physician are shown in Table 1. An AP field was utilized, along with two others
at gantry angles of 210 and 125 degrees, all with 18X energy and weighted equally. To reduce
hotspots and improve conformality, a 40-degree wedge with heel left was added to the beam at a
gantry angle of 210. The treatment fields were blocked around the PTV with a 1 cm margin. A
 2

transverse screenshot mid-PTV from the 3D plan can be viewed in Figure 1. All objectives were
met for this patient using this technique.

Figure 1. Transverse slice of 3D plan. Contoured structures are identified as follows: red-PTV,
pink-stomach, blue-liver, yellow-lungs.
 3

Table 1. PTV and organs at risk constraints.

The Supafirefly technique was then applied to this same patient, utilizing the same PTV
and organs at risk constraints as for the 3D plan (Table 1). Additional planning structures were
also suggested and evaluated for this technique, including a 1.5 cm ring around the PTV
(fsring15mm) and an avoidance area 1.5 cm away from the PTV, encompassing all of the patient
with an additional 3 slices superior and inferior to the PTV (fsNTavoid). 6 gantry angles are
specified for the Supafirefly technique: 60, 80, 120, 140, 160, 180, and 200-degrees. The IMRT
planning was relatively simple; I only used a few constraints on the heart and on the lungs in
order to meet the planning objectives and used patient rings to conform the dose. I did not use
the added structures for my final treatment plan, as I didnt find them helpful with the current
method in which I configure my IMRT constraints. A transverse screenshot mid-PTV for the
Supafirefly plan can be viewed in Figure 2. Again, all objectives were met for this patient using
this technique.
 4

Figure 2. Transverse slice of Supafirefly plan. Contoured structures are identified as follows:
red-PTV, pink-stomach, blue-liver, yellow-lungs.

The 3D and Supafirefly techniques offered similar outcomes regarding some objectives
and differing outcomes in others. All objectives as dictated by the physician with each plans
results are listed in Table 2. Target coverage and maximum dose points between the plans are
similar. Surprisingly (to me), all volume-specified lung doses were lower in the 3D plan,
although not by much. The heart doses, however, were significantly lower in the Supafirefly
plan. The remainder of the results for the objectives for organs at risk were inconsequential, in
my opinion; both the 3D and Supafirefly plans met all objectives and had very similar results.
The Supafirefly technique definitely helped me to create a more conformal plan, as is evidenced
in Figure 2 and by the evaluation of the fsring15mm and fsNTavoid structures. 31.28% of the
fsring15mm structure received 5040 cGy in the 3D plan but only 5.62% in the Supafirefly plan.
The fsNTavoid structure had a similar outcome when comparing volumes receiving 2000 cGy:
32.33% for the 3D plan and 5.66% for the Supafirefly plan.
 5

Table 2. 3D plan objectives summary.

Structure Constraint 3D plan Supafirefly plan
PTV5040 V5040 cGy 95% 95.07% 95%
SpinalCord Dmax 4300 cGy 3632 cGy 3327 cGy
Kidney_L V 1500 25% 5% 2.78%
Kidney_R V 1500 25% 0% 0%
LargeBowel V 4500 25% 0% 0%
Dmax 5300 cGy Dmax: 1100 cGy Dmax: 663 cGy
SmallBowel V 4500 25% 0% 0%
Dmax 5300 cGy Dmax: 122 cGy Dmax: 145 cGy
Stomach V 4500 100% 28.78% 26.78%
Dmax 5300 cGy Dmax: 5295 cGy Dmax: 5284 cGy
Liver Dmean 2800 cGy Dmean: 1039 cGy Dmean: 1049 cGy
V 3000 30% 12.24% 5.66%
Lungs V 2000 35% 4.43% 4.73%
V 500 50% 14.32% 15.89%
Heart V 3000 50% 26.86% 14.80%
V 4000 35% 17.09% 9.29%
V 5000 5% 9.27% 4.35%

If I were to choose a treatment planning technique to use in the future when given the
option of 3D or Supafirefly, I would start with a 3D plan. Although the heart doses were lower
with the Supafirefly technique, the heart dose objectives were still easily met with the 3D plan.
My clinical internship site uses Elekta Monaco treatment planning systems for IMRT planning
with a Monte Carlo algorithm for dose calculations, which is accurate but very time consuming.
A 3D plan is quicker to create and is much more cost effective for the patient than an IMRT plan.
The added planning structures were useful in evaluating the conformality of my plans, but like I
mentioned earlier, I didnt use them at all in the actual planning process. The main benefit of the
Supafirefly technique was the conformality of the isodose lines, but I dont feel that this alone
would be convincing enough (for me) to bypass a 3D plan initially.
 6

References

1. Key Statistics for Esophageal Cancer. American Cancer Society Web site.
https://www.cancer.org/cancer/esophagus-cancer/about/key-statistics.html. Published 2017.
Updated June 14, 2017. Accessed October 28, 2017.
2. Khan FM, Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA:
Lippincott, Williams & Wilkins; 2012:465.
3. Nutting CM, Bedford JL, Cosgrove VP, et al. A comparison of conformal and intensity-
modulated techniques for oesophageal radiotherapy. Radiother Oncol. 2001;61(2):157163.
4. Palmer M. Advances in Treatment Planning Techniques and Technologies and
Techniques for Esophagus Cancer. [PowerPoint]. Houston, TX: The University of Texas MD
Anderson Cancer Center.