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

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, affecting roughly 1 in 8
women.1 These facts are why this disease is t the forefront of numerous clinical trials and case
studies. The radiation oncology community continues to search for the most effective modalities
to fight breast cancer while providing an optimal treatment experience for patients. An integral
part of a comprehensive approach to patient treatment is to focus on side effects of radiotherapy
such as minimizing 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). Post mastectomy radiation therapy utilizes an oblique beam arrangement with an
appropriate megavoltage (MV) energy to deliver a prescribed dose to the chest wall soft tissue,
local skin borders, axilla 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
create a challenging radiotherapy treatment environment.2,3 The frequently used 6 MV energy
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reaches 100% effectiveness or depth of electronic equilibrium (Dmax) at 1.5 cm which, when
used with oblique fields, produces an under dose to the skin in the treatment area. An under dose
allows a potential and unacceptable chance of reoccurrence.2,3 In order to counteract the loss of
prescription dose to the skin in the treatment area, the set-up procedure and treatment planning
includes a tissue-equivalent bolus (TEB).2,3,4,5
Tissue-equivalent bolus may be composed of various materials including SuperStuff,
Elasto-Gel and Superflab. The key variable is that the bolus emulates human soft tissue and has a
density of 1 g/ml.6,7 Due to its 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. Because of this essential treatment variable, each patient is
subject to varying levels of skin toxicity depending upon the location of their prescribed
treatment volume.9,10,11
This case study will 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 data is to determine if one method will produce 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
For this case study, two facilities were involved in the collection of patient data. Kaiser
Permanente Medical Center in South San Francisco (KPSSF) is one of the largest cancer care
facilities in the Bay Area, providing radiation treatments for approximately 100 to 120
outpatients per day. KPSSF has accreditation through the National Accreditation Program for
Breast Centers from American College of Surgeons (NAPBC), ASTRO Accreditation Program
for Excellence (APEx), and the Commission on Cancer Accreditation from the American
College of Surgeons (CoC). The cancer center employs 60 employees including eight radiation
oncologists. The center has been designated as a Regional Referral Center within Kaiser
Permanente and offers specialized services including stereotactic radiosurgery.
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Penrose Cancer Center (PCC), located in Colorado Springs, has been providing cancer
care for patients since 1939. The center has accreditation through the American College of
Radiology (ACR), The Joint Commission (JCAHO), and various other groups. PCC boasts a
wide variety of treatment modalities. It has three linear accelerators including a Varian Trilogy,
TrueBeam, and a CyberKnife Robotic Radiosurgery System.
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. As can be seen by
examining Table 1,

Age Laterality Ethnicity Stage T N M G Bolus Surgical MOVED TO

Type Procedure TABLES
SECTION
39 Left Caucasian IIB 2 1 0 1 Elastogel

Ag Laterali Ethnici Stag T N M G Bolus Surgical MOVED TO

e ty ty e Type Procedure TABLES
SECTION

47 Left Caucasi 2 2 0 Elastog

an el

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. Table 4 provides a breakdown of the surgical
decisions made by our patient population.

Table 4.
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Surgical Procedure
Breast Reconstruction Individual info to be added
Chest Wall To table 3

To establish a study population with as few inconsistencies as possible, all the patients
chosen for this study were treated with a 3-field technique of two tangents with a supraclavicular
field. This is a an acceptable method of breast cancer treatment with radiation. For these patients,
the oblique fields were treated with 6 MV energy photon beams while the supraclavicular field
utilized a 15 MV energy photon beam. All of this was done to form a common baseline from
which we can examine the patients and develop informed conclusions.
For this study, patients were selected based on the use of bolus in their radiation
treatment regimen. As can be noted in Tables 2 and 3, the patient data is organized by the center
at which the information was acquired. The Kaiser Permanente data focused on the use of 3 mm
bolus every day 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. At
one center, Pinnacle was used, and the other center utilizes Eclipse. The heart, esophagus, and
both lungs are contoured by the medical dosimetrist which allows for monitoring of the dose
received by each organ from the subsequent radiation treatment plan. 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. This area
was carefully examined and outlined by the respective physician. The PTV took into
consideration the size of the patient’s GTV and applied a margin to this structure. The overall
purpose of this border was to account for any residual disease or potential movement of the
patient during treatment. Both volumes were vital in creating the plans used in this study.
Treatment Planning
All patients in this study were treated using a mono-isocentric technique consisting of 2
obliques and a supraclavicular field. This is a standard procedure in the treatment of
mastectomies with regional nodal involvement. Each patient was treated with 6 MV photon
beams for the tangent fields and variable energies treating the supraclavicular field depending on
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patient anatomy. The consistency among our patient population was maintained to provide a
baseline from which we can draw educated conclusions.
The treatment fields used in this study had borders that were based on RTOG protocols.12
The medial border was placed at patient midline with the lateral boundary being 2 centimeters
beyond the breast tissue. The superior field edge matched the inferior border of the
supraclavicular field. Finally, the tangential inferior border was placed 2 centimeters 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,
they 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 axilla levels 1-3, supraclavicular and internal 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. The heart, esophagus, and both lungs are contoured by the medical dosimetrist which
allows for monitoring of the dose received by each organ from the subsequent radiation
treatment plan.
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. This resulted in 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.
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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.

Oblique SCV CW or Dose Max

Energy Energy Recon

6x 6x CW 107.70%

Tangent SCV CW Dose Max

Energy Energy or
Recon

6x 15x recon

Plan Analysis and Evaluation

Table 7. Skin Toxicity Comparison

5 mm every other day vs 3 mm daily
Grou Week 1 Week 2 Week 3 Week 4 Week 5
ps
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)
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G1-B 85 15 0 55% 45 0 20 70 10 0% 70 25 0 35 65
(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-B 85 15 0 55% 45 0 20 70 10 0% 70 25 0 35 65
(n=2 % % % % % % % % % % % % %
0)
G3- 100 0% 0 100 0% 0 0% 100 0% 0% 100 0% 0 100 0%
A % % % % % % % %
(n=1
)
G3-B 83. 16. 0 50% 50 0 16. 66. 16. 16. 50 33. 0 33. 66.
(n=6 3% 7% % % % 6% 7% 7% 7% % 3% % 3% 7%
)
G4- 100 0% 0 0% 100 0 0% 100 0% 0% 100 0% 0 50 50
A % % % % % % % % %
(n=2
)
G4-B 85. 14. 0 64.3 35. 0 21. 71. 7.5 0% 78. 21. 0 35. 64.
(n=1 7% 3% % % 7% % 1% 4% % 6% 4% % 7% 3%
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%
(n=3
)
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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://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://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://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://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://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://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://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://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

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%
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6x 6x CW 110.30%
6x 6x CW 109.90%
6x MIXED CW 110.30%
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%

Tangent SCV CW Dose Max

Energy Energy or
Recon

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
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6x 15x recon
6x 15x recon
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