1

A Case Study Comparison of Skin Toxicity in Patients Receiving Chestwall Irradiation

Using 5 mm Bolus Every Other Day vs. 3 mm Bolus Daily

Authors: Amy Cate, B.S., R.T.(T), Dan Frieling, B.S., R.T.(T), Jason Laher, M.S., R.T.(T),
Bianca Tester, B.S., R.T.(T), Ashley Hunzeker, M.S., CMD, Lee Culp, M.S., CMD, Nishele
Lenards, PhD., CMD, R.T.(R)(T), FAAMD; Alyssa Olson, MS, R.T.(T), CMD

Abstract

Introduction: The purpose of this case study is to…

Case Description:

Conclusion:

Key words:

Introduction
Breast cancer is one of the most common forms of cancer in women, affecting roughly 1
in 8.1 The radiation oncology community continues to search for the most effective modalities to
treat breast cancer while providing an optimal treatment experience for patients. An integral
focal point for patient treatments is side effect management, of which can include radiotherapy
and the goal to minimize skin toxicity while providing the prescribed therapeutic dose to the
treatment area. One effective technique in treating breast cancer is post-mastectomy radiation
therapy (PMRT). Historically, PMRT utilizes an oblique beam arrangement with an appropriate
megavoltage (MV) energy to deliver a prescribed dose of radiation to the chest wall, soft tissue,
local skin borders, axillary lymph nodes, and remaining breast tissue as delineated by the treating
physician.2 The curvature of the chest wall and varying densities in the bone, lung and soft tissue
can create a challengee for radiotherapy treatment planning.2,3 The frequently used 6 MV energy
reaches 100% effectiveness or depth of electronic equilibrium (Dmax) at 1.5 cm which, when
used with oblique fields, under-doses the skin surface in the treatment area, posing a risk for
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recurrence.2,3 In order to counteract the loss of prescription dose to the skin surface in the
treatment area, a tissue-equivalent bolus (TEB) is often used.2-5
Tissue-equivalent bolus may be composed of various materials including SuperStuff,
Elasto-Gel and Superflab. Bolus emulates human soft tissue and has a density of 1 g/ml.6,7 Due
to the density similarity, the radiation beam interacts with the bolus in the same manner as soft
tissue. When used appropriately, this can negate the “skin sparing” effect of the 6 MV photons
used in PMRT.5,8 As a result, the bolus allows the Dmax energy of the 6 MV photon beams to
encompass the treatment area more effectively, causing an increased dose of radiation at the skin
surface. Each patient is subject to varying levels of skin toxicity depending upon the location of
their prescribed treatment volume.9-11
This case study focus on the difference between using 3 mm of TEB for every
radiotherapy treatment versus using 5 mm of TEB for every other treatment. The goal in
analyzing this datawas to determine if one method produced less skin toxicity in patients while
maintaining an acceptable therapeutic dose in the treatment area. The 3 mm bolus consisted of
Superflab or Elasto-Gel while the 5 mm bolus consisted of Elasto-Gel.

Case Description

Patient Selection
The study was retrospective in nature. All patients selected for this study were previously
treated at 2 different cancer centers and varied in age and demographics. It is common for
patients with breast cancer to experience a surgical procedure. A mastectomy or lumpectomy is
typically performed to extract the cancerous tissue. Breast reconstruction is a subsequent
cosmetic surgery which reshapes the breast using an artificial implant or a piece of tissue from
another part of the body. A sizable portion of the patients in our case study opted to undergo this
procedure. However, some women declined and instead chose to leave the post-surgery chest
wall unaltered.
All the patients chosen for this study were treated with a 3-field technique of two
tangents with a supraclavicular field. For consistency purposes, the tangential fields were treated
with 6 MV energy photon beams while the supraclavicular fields utilized either 15 MV or mixed
energy photon beams.
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For this study, patients were selected based on the use of bolus in the radiation treatment
regimen. As can be noted in Tables 2 and 3, the patient data was organized by the center at
which the information was acquired. The Kaiser Permanente data focused on the use of 3 mm
bolus daily while the Penrose data centered on 5 mm bolus every other day. This was done due
to the commonality of the respective technique at each site.
Target Delineation
The facilities involved in this case study used different treatment planning systems (TPS).
At one center, Pinnacle was used, and the other center utilizes Eclipse. The heart, esophagus, and
both lungs were contoured by the medical dosimetrist. For each patient, the physician delineated
a gross tumor volume (GTV) and planning target volume (PTV). The GTV was designed to
encompass the visible extent of the patient’s disease as seen on CT and was outlined by the
respective physician. Based on the size of the patient’s GTV, custom margins were applied to
create a PTV structure.
Treatment Planning
All patients in this study were treated using a mono-isocentric technique consisting of 2
opposing tangents and a supraclavicular field. Each patient was treated with 6 MV photon beams
for the tangent fields and variable energies treating the supraclavicular field depending on patient
anatomy.
The treatment field borders used in this study were based on RTOG protocols.12 The
medial border was placed at patient midline with the lateral boundary 2 cm beyond the breast
tissue. The superior field edge matched the inferior border of the supraclavicular field. Finally,
the tangential inferior border was placed 2 cm below the inframammary fold.
The borders for the supraclavicular field were different than those used for the tangential
fields. Medially, the field edge formed a vertical line at midline extending from the first costal
interspace to thyro-cricoid groove. The lateral border started at the acromioclavicular joint,
bisecting the humeral head, while excluding as much of the shoulder as possible. Superiorly, the
border extended across the neck and trapezius muscle to the acromial process to ensure the entire
supraclavicular fossa was included. Inferiorly the border matched the superior edge of the
tangential fields.
The borders for both the tangential and supraclavicular fields were designed to include
the entire PTV as well as the axillary nodal levels 1-3, and supraclavicular and internal
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mammary lymph nodes. At the time of simulation, the physicians placed radiopaque wiring to
define the intended treatment borders of the patient’s chestwall. These borders were then used in
conjunction with RTOG protocols to create the appropriate field dimensions.
As is the case with all radiation treatments, there are various critical structures that are
adjacent to the patient’s target volume. Given that patients involved in this case study are
undergoing radiation treatments to the chestwall, the organs in question are within the thoracic
cavity.
To maintain a baseline from which reliable conclusions can be drawn, patients examined
in this study received the same radiation dose. Each patient had a prescription of 180 cGy daily,
for 25 fractions to a total dose of 4500 cGy. Both the nodal and chestwall volumes were each
given the full prescription dose. The only aspect of the prescription that varied between patients
was the thickness and variation of the bolus used.
Finally, the maximum dose remained relatively consistent among the study population
depending on the location from which the data was gathered. The point of maximum dose was
either slightly above or below 110% of the prescribed dose for patients treated at. However,
patients treated at had hot spots around 120% of the prescribed dose. This information is
summarized in tables 5 and 6.

Plan Analysis and Evaluation

Table 7. Skin Toxicity Comparison

5 mm every other day vs 3 mm daily
Gro Week 1 Week 2 Week 3 Week 4 Week 5
ups
Toxi 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2
city
G1- 94. 5.3 0 36.8 63. 0 5.3 94. 0% 0% 89. 10. 0 26. 73.
A 7% % % % 2% % % 7% 5% 5% % 3% 7%
(n=1
9)
G1- 85 15 0 55% 45 0 20 70 10 0% 70 25 0 35 65
B % % % % % % % % % % % % %
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(n=2
0)
G2- 100 0% 0 33.3 66. 0 0% 100 0% 0% 100 0% 0 66. 33.
A % % % 7% % % % % 7% 3%
(n=3
)
G2- 85 15 0 55% 45 0 20 70 10 0% 70 25 0 35 65
B % % % % % % % % % % % % %
(n=2
0)
G3- 100 0% 0 100 0% 0 0% 100 0% 0% 100 0% 0 100 0%
A % % % % % % % %
(n=1
)
G3- 83. 16. 0 50% 50 0 16. 66. 16. 16. 50 33. 0 33. 66.
B 3% 7% % % % 6% 7% 7% 7% % 3% % 3% 7%
(n=6
)
G4- 100 0% 0 0% 100 0 0% 100 0% 0% 100 0% 0 50 50
A % % % % % % % % %
(n=2
)
G4- 85. 14. 0 64.3 35. 0 21. 71. 7.5 0% 78. 21. 0 35. 64.
B 7% 3% % % 7% % 1% 4% % 6% 4% % 7% 3%
(n=1
4)
G5- 100 0% 0 33.3 66. 0 0% 100 0% 0% 88. 11. 0 22. 77.
A1 % % % 7% % % 9% 1% % 2% 8%
(n=9
)
G5- 85. 14. 0 42.9 57. 0 14. 85. 0% 0% 85. 14. 0 14. 85.
A2 7% 3% % % 1% % 3% 7% 7% 3% % 3% 7%
(n=7
)
G5- 100 0% 0 33.3 66. 0 0% 100 0% 0% 100 0% 0 66. 33.
A3 % % % 7% % % % % 7% 3%
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(n=3
)
G6- 77. 22. 0 55.5 44. 0 22. 77. 0% 0% 100 0% 0 44. 55.
B1 8% 2% % 6% 4% % 2% 8% % % 4% 6%
(n=9
)
G6- 75 25 0 50% 50 0 0% 75 25 0% 25 75 0 0% 100
B2 % % % % % % % % % % %
(n=4
)
G6- 100 0% 0 66.7 33. 0 33. 66. 0% 0% 66. 33. 0 33. 66.
B3 % % % 3% % 3% 7% 7% 3% % 3% 7%
(n=3
)

Conclusion
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References
1. Washington CM, Leaver DT. Principles and Practice of Radiation Therapy. 3rd ed.
Philadelphia: Elsevier Health Sciences; 2009.
2. Healy E, Anderson S, Cui J, et al. Skin dose effects of postmastectomy chest wall radiation
therapy using brass mesh as an alternative to tissue equivalent bolus. Pract Radiat Oncol.
2013; In Press. https://dx.doi.org/10.1016/j.prro.2012.05.009
3. Hsu SH, Roberson PL, Chen Y, et al. Assessment of skin dose for breast chest wall
radiotherapy as a function of bolus material. Phys Med Biol. 2008;53:2593-2606.
http://iopscience.iop.org/article/10.1088/0031-9155/53/10/010/meta
4. Andic F, Ors Y, Davutoglu R, et al. Evaluation of skin dose associated with different
frequencies of bolus applications in post-mastectomy three-dimensional conformal
radiotherapy. J Exp Clin Cancer Res. 2009;28-41.
https://dx.doi.org/10.1186/1756-9966-28-41
5. Khan FM. The Physics of Radiation Therapy. 3rd ed. Lippincott Williams and Wilkins,
Philadelphia; 2003:283.
6. Visscher S, Barnett E. Comparison of bolus materials to highly absorbent
polypropylene and rayon cloth. J Med Imaging Radiat Sc. 2017;48(1):55-60.
https://dx.doi.org/10.1016/j.jmir.2016.08.003
7. Humphries S, Boyd K, Cornish P, & Newman F. Comparison of super stuff and paraffin
wax bolus in radiation therapy of irregular surfaces. Med Dosim. 1996;21(3):155-157.
https://dx.doi.org/10.1016/0958-3947(96)00076-3
8. Letourneau M, Hogue J, Desbiens C, Theberge V. Outcomes in postmastectomy patients
treated by ajuvant radiation therapy without application of bolus. Int J Radiat Oncol Biol
Phys. 2012;84(3)S247. https://dx.doi.org/10.1016/j.ijrobp.2012.07.641
9. Pignol JP, Vu TT, Mitera G, et al. Prospective evaluation of severe skin toxicity and
pain during postmastectomy radiation therapy. Int J Radiat Oncol.Biol Phys.
2015;91(1):157-164. https://dx.doi.org/10.1016/j.ijrobp.2014.09.022
10. Asher D, Johnson P, Dogan N, et al. Acute skin toxicity is comparable between brass
bolus and 0.5 mm tissue equivalent bolus among women receiving postmastectomy
irradiation using mixed energy photons. Int J Radiat Oncol Biol Phys. 2017; 99(2).
https://dx.doi.org/10.1016/j.ijrobp.2017.06.597
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11. Parekh A, Dholakia A, Zabransky D, et al. Predictors of radiation-induced acute skin

toxicity in breast cancer at a single institution: Role of fractionation and treatment
volume. Adv in Radiat Oncol. 2018; 3(1): 8-15.
https://dx.doi.org/10.1016/j.adro.2017.10.007
12. White J, Tai A, Arthur D, et al. Breast Cancer Atlas for Radiation Therapy Planning:
Consensus Definitions. RTOG: Radiation Therapy Oncology Group.
https://www.rtog.org/CoreLab/ContouringAtlases/BreastCancerAtlas.aspx.
Accessed June 26, 2016.
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Tables
Age Laterality Ethnicity Stage T N M G Bolus Surgical
Type Procedure
39 Left Caucasian IIB 2 1 0 1 Elastogel
85 Right Caucasian IIB 2 1a 0 2 Superflab
73 Right Asian IIB 2 1a 0 2 Superflab
45 Left Asian IIB 2 1 0 3 Superflab
42 Left Caucasian IIIA 2 2a 0 3 Elastogel
46 Left Caucasian IIIA 3 1c 0 1 Superflab
45 Left Asian IIB 2 1 0 Superflab
64 Right Caucasian IIIB 3 2a 0 Superflab
53 Left Pacific IIB 3 1a 0 3 Superflab
Islander
51 Left Pacific IIIC 3 3a 0 2 Superflab
Islander
63 Right Caucasian IIB 2 1c 0 2 Superflab
49 Right Hispanic IB 1c N1mi 0 3 Superflab
75 Left Pacific IIIC 4d 3b 0 3 Superflab
Islander
50 Right Caucasian X Superflab
54 Right Asian IIIA 3 1 0 Superflab
29 Left Asian X 2 Superflab
53 Left Caucasian IIA 1c 1a 0 2 Superflab
86 Left Caucasian IIIB 4b 2a 0 3 Superflab
55 Left Asian IIA 1c 1a 0 2 Superflab
53 Right Hispanic IIA 3 1 0 3 Superflab
44 Left Caucasian IIA 1a 1 0 3 Superflab
59 Left Pacific IIB 2 1 0 2 Elastogel
Islander
37 Right Asian 0 is 0 0 2 Superflab

Age Laterality Ethnicity Stage T N M G Bolus Surgical Procedure

Type
47 Left Caucasian 2 2 0 Elastogel
48 Left Caucasian 2 1a 0 3 Elastogel
47 Right Caucasian IIIA 3 1 0 Elastogel
69 Left Caucasian IV 4d 3 1 3 Elastogel
61 Left Caucasian IIIA 3 2a 0 2 Elastogel
84 Left Caucasian 2 1a 0 3 Elastogel
53 Left Hispanic 2 2a 0 1 Elastogel
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25 Right Caucasian IIIC 2 3a 0 Elastogel

46 Right Caucasian IIB 2 1a 0 1 Elastogel
45 Left Other - 4d 1 1 3 Elastogel
non
Hispanic
47 Right Caucasian 2 2a 0 2 Elastogel
47 Right Hispanic IIA 1 1a 0 2 Elastogel
55 Right Asian IIA 2 0 0 2 Elastogel
57 Left Caucasian IIIC 1c 1a 0 2 Elastogel
42 Left Caucasian I 1c 1a 0 1 Elastogel
35 Left Caucasian IV 2 3b 1 2 Elastogel
53 Right Caucasian IIB 2 1a 0 2 Elastogel
54 Right Caucasian IIIA 2 2a 0 1 Elastogel
54 Right Caucasian IIB 2 1a 0 3 Elastogel
46 Left Caucasian IIIA 2 2a 0 3 Elastogel

Kaiser Permanente Data

Oblique Energy SCV CW or Dose Max
Energy Recon

6x 6x CW 107.70%
6x 6x CW 108.00%
6x 6x CW 108.10%
6x 6x CW 108.00%
6x 6x CW 109.80%
6x 6x CW 109.00%
6x 6x CW 110.30%
6x 6x CW 110.80%
6x 6x CW 109.50%
6x 6x CW 110.30%
6x 6x CW 109.90%
6x MIXED CW 110.30%
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6x MIXED CW 110.50%
6x MIXED CW 110.00%
6x MIXED CW 110.50%
6x MIXED recon 109.60%
6x MIXED CW 110.80%
6x MIXED CW 108.80%
6x 15x CW 110.60%
6x 15x recon 115.10%
6x 15x recon 108.90%
6x 15x CW 110.20%
6x NONE CW 108.70%

Penrose Cancer Center Data

Tangent Energy SCV CW or Dose

Energy Recon Max

6x 15x recon
6x 15x recon
6x 15x recon
6x 15x CW
6x 15x recon
6x 15x CW
6x 15x recon
6x 15x CW
6x 15x recon
6x 15x recon
6x 15x recon
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6x 15x recon
6x 15x CW
6x 15x recon
6x 15x recon
6x 15x CW
6x 15x CW
6x 15x recon
6x 15x recon
6x 15x recon