1

Effects of Varying Bolus Thickness on Skin Dose for VMAT and Helical Tomotherapy
Chest Wall Irradiation: A Case Study
Authors: Alyx Haasl, B.S., R.T.(T), Destiny Jacobs, B.S., R.T.(T), CMD, Ashley Hunzeker, M.S,
CMD, Nishele Lenards, M.S., CMD, R.T.(R)(T), FAAMD
Medical Dosimetry Program at the University of Wisconsin-La Crosse, WI
Abstract:
Introduction: The purpose of this study was to evaluate the necessity of bolus during volumetric
modulated arc therapy (VMAT) and helical tomotherapy (HT) for post mastectomy radiation
therapy patients. Four patients were evaluated from both VMAT and HT treatment plans; each of
those patients had three plans representing each bolus schema.
Case Description: Four patients were chosen for planning and dose evaluation. All patients
were locally advanced breast cancer patients without breast reconstruction surgery. Two patients
were planned and evaluated using VMAT at clinic A and two patients were planned and
evaluated with HT at clinic B. A dosimetric comparison was performed to determine whether
bolus was needed to achieve proper surface, skin, and planning tumor volume (PTV) coverage
for chest wall patients treated with a VMAT and HT based plan. Bolus schemas evaluated
included 1.0 cm bolus daily, 0.5 cm bolus daily, and no bolus.
Conclusion: All plans were evaluated based on tumor volume coverage and superficial dose.
The superficial dose was defined as the volumetric area 3 mm inside the body contour at the
level of the PTV. The findings of this study showed that all evaluated plans were within the
acceptable mean dose coverage for the superficial volume. This case study concludes that
VMAT and HT planning techniques for post mastectomy without breast reconstruction do not
require bolus for superficial coverage.
Keys Words: Helical tomotherapy, volumetric modulated arc therapy, chest wall irradiation,
bolus
Introduction
Breast cancer is the most common malignancy, besides skin cancer, among women.1 The
reported incidence remains high due to the increased and continuous use of breast cancer
screenings. Mortality rates have decreased as a result of new screening procedures detecting
breast disease at earlier stages. Advancements in technology, radiation therapy, chemotherapy,

and surgery, have played a crucial role in extending the life of breast cancer patients, as well as
increasing their quality of life. Patients who have high risk of recurrence benefit from
advancements and the utilization of multiple treatment modalities.2
Non-reconstructed post mastectomy radiation therapy is one common and effective
modality and allows for optimal treatment of the lymphatics and surgical resection scar.2 Post
mastectomy radiation treatment techniques vary among institutions. Most institutions use some
form of bolus, a tissue equivalent material, to allow prescription dose to be delivered
superficially to the surgical scar and lymphatics.2,3 Most of the materials used for bolus mimic the
density of the bodys natural fatty tissue.5 Common bolus materials include but are not limited to:
water, superflab or other vinyl based material, Vaseline and oil based substances.4,5,6 For chest
wall patients, it is difficult to reproduce bolus setup daily, so materials such as a mesh or vinyl
based flab can easily be laid on a patient with constant thickness.4,6
Although bolus has been proven to help with chest wall 3D conformal radiation
treatments, it may be deemed unnecessary to use bolus every day. There are a variety of
scheduling schemes. Common bolus treatment techniques for chest wall patients include using
daily, every other day, or no bolus.2 Extensive research has yielded very little documentation
concerning the effects of bolus on surface dose when using an intensity modulated radiation
therapy (IMRT) technique for chest wall irradiation
For cases where the treatment volumes are close to critical structures, it is crucial to
utilize advanced techniques such as IMRT for chest wall planning. Studies have shown that both
VMAT and HT planning provide exceptional PTV coverage and avoid organs at risk (OR).7
When comparing tumor volume coverage and OR avoidance between treatment techniques,
IMRT plans are considerably superior to 3D conformal plans.8 However, it is questionable
whether bolus is necessary due to VMAT and HT advanced planning capabilities, which allows
for better superficial coverage when needed. For example, IMRT head and neck patients show
significant superficial reaction without the use of bolus during treatment delivery.
Many studies have compared the use of 3D conformal radiation therapy against IMRT
for post mastectomy patients.2,4 The use of bolus with IMRT techniques has yet to be evaluated
and proven necessary, or unnecessary, for superficial dose coverage. The purpose of this study
was to evaluate the necessity of bolus during VMAT and HT treatments for post mastectomy
radiation therapy patients. Four patients were evaluated from both VMAT and HT treatment

plans; each of those patients had three plans representing each bolus schema. A dosimetric
comparison was performed to determine whether bolus was needed to achieve proper surface,
skin, and PTV coverage for chest wall patients treated with a VMAT and HT based plan. Bolus
schemas evaluated included 1.0 cm bolus daily, 0.5 cm bolus daily, and no bolus.
Case Description
Patient Selection and Setup
Two patients were selected to be evaluated with a VMAT treatment planning technique at
clinic A. Qualifications for patient selection included non-reconstructed post-mastectomy
patients greater than 18 years of age. These patients were evaluated for node positive status in
order to treat the supraclavicular nodal region. For VMAT based plans, both patients were
simulated in a supine position on a General Electric large bore Computed Tomography (CT)
simulator. The images were obtained at 2.5 mm slice thickness. Each patient was placed on an
Accufix breast board to obtain the correct chest slant. A Vac-lok immobilization bag was placed
on top of the board to immobilize and replicate the positioning superior to the waist. The arm of
the affected side was bent above the head with the head turned away from the side of treatment.
An angle sponge was placed under the knees for comfort, and the feet were banded for
reproducibility. Wires were placed on the patients skin by the radiation oncologist to mark the
post-mastectomy scar as well as the medial, lateral and inferior clinical borders of the chest wall
tissue.
Both HT patients were simulated at clinic B in the supine position on a Siemens Large
Bore CT simulator. The images were obtained in 2 mm slices. Each patient was placed on a
CIVCO wing board with a standard clear headrest. Both arms were placed above the patients
head with the patient holding the wing board pegs. The scanning parameters set by the radiation
therapist included the base of chin through the entire thoracic region. Each patient was marked
using a three point lead localization marker technique in addition to making the mastectomy
scars visible on the CT images. After the scan was completed, the patient setup marks were
tattooed.
Target Delineation
Treatment target volumes for VMAT planning were defined by the radiation oncologist.
The Clinical Tumor Volume (CTV) for the chest wall area was drawn first. The CTV for the
supraclavicular areas were defined secondly and included nodal volumes of the supraclavicular

nodes and axillary nodes. The two CTV volumes were combined to create a CTV treatment
volume (CTV_TX). The CTV_TX was expanded by 3 mm to create a PTV treatment volume
(PTV_TX). The PTV_TX was then extracted 4 mm away from the patients body contour to
create a PTV evaluation structure (PTV_eval) in order to accommodate the buildup region that
was necessary for the Eclipse treatment planning systems (TPS) optimization algorithm for
VMAT treatment planning. The OR were drawn to include skin, ipsilateral lung, contralateral
lung, esophagus, spinal cord, and heart.
Treatment target volumes for HT planning were defined by the radiation oncologist on
the CT images after they were transferred to the Pinnacle TPS. The chest wall was contoured to
extend to the body contour (PTV_chestwall). The chest wall contour was then retracted from the
external surface by 5 mm to account for HT superficial buildup and labeled as the PTV_eval.
The PTV_eval excluded the lung volume on the ipsilateral side. Nodal involvement contours
were determined based on radiation oncologists evaluations (PTV Nodal Volumes). The OR
were drawn and included the skin, ipsilateral and contralateral lung, heart, contralateral chest
wall, and spinal cord. Along with the target volumes and OR, planning structures were also
created. A complete block was drawn, known as a posterior block. This block was used to
completely block beams from entering and exiting the lungs and spinal cord. The posterior block
was drawn to cover the entire contralateral posterior lung to the middle of the ipsilateral lung
(Figure 1). Planning rings were also created by expanding the PTV by 5 mm and then creating a
1.3 cm circumferential structure (HDRing). This forced dose into the target volume. An
additional 5 cm ring was also created off of the HDRing while limiting the structure from exiting
the external contour. This was used to keep higher doses out of normal tissues and pull higher
doses into the target volume (Figure 2).
Treatment Planning
For VMAT planning, the radiation oncologist prescribed a total dose of 50.4 Gy to be
delivered to the PTV_TX volume at 1.8 Gy per day. The plan was generated using 6 MV for all
arc rotations. The isocenter for each plan was placed at the center of the tumor volume. The
VMAT plan for patient 1 and patient 2 included arc rotations starting at 120 and ending at 350.
Both VMAT patients were right chest wall. There were 4 arcs to be setup for each plan, 2 rotating
clockwise and 2 rotating counter clockwise (Figure 3). All collimators were rotated 15 with
respect to the direction of the gantry rotation. For each arc, the collimator setting was checked to

make sure the tumor volume was completely encompassed within the y-jaw setting (Figure 4).
For the x-jaw setting, a maximum of 15 cm was set with X1 for one rotation completely
including the tumor volume and X2 complimenting the X1 jaw totaling 15 cm. This was done
with the same directional arc to compliment the collimator settings of each beam.
For HT planning, the radiation oncologist prescribed a total dose of 50.4 Gy to the
PTV_Chestwall and PTV nodal volumes. Tomotherapy treatment machines utilized a 6 MV
energy. Planning parameters set by the medical dosimetrist included the following: delivery
mode, jaw mode, field width, helical pitch, calculation grid, and modulation factor. For this case
study a helical delivery mode with a dynamic jaw was selected in all plans. Field lengths for all
plans were set at 5 cm due to the large treatment field. However, pitch and modulation factor
varied among the two patients. Once the parameters were set, the targets and OR were brought
into the optimization phase where the medical dosimetrist worked to develop the optimal
treatment plan.
The VMAT plans were optimized with appropriate constraints for the OR and PTV_eval
volumes. The tumor volume goal was to deliver 95% of the prescribed dose to 95% of the
PTV_eval. After a base plan was created that included all the above criteria, bolus was added.
Bolus schemas were as followed; no bolus, thicknesses of 0.5 cm daily and 1 cm daily. The
superficial dose was evaluated by generating a structure which included an area 3 mm internally
from the body contour in the region of the treatment only (Figure 5).
The HT plans were optimized with appropriate constraints for the OR and PTV_eval
volumes. The PTV_eval goal was to deliver 95% of the prescribed dose to 95% of the tumor
volume per physician planning orders. The HT treatment plans also contained the same bolus
schemas of no bolus, thicknesses of 0.5 cm daily and 1 cm daily. The superficial dose was
evaluated by using the same structure as the VMAT plan.
Plan Analysis & Evaluation
Both VMAT and HT techniques generated plans that were clinically useful. All critical
structures met the planning requirements including the target coverage. Thermoluminescent
dosimeters (TLDs) were exposed to gather the superficial dose data along the mastectomy scar
for two HT treatment plans (Figures 6 & 7). In both the VMAT and HT, the chest wall target
coverage desired was 95 % of the treatment volume was to receive 95 % of the prescription dose
(47.88 Gy). In all of the VMAT and HT plans, greater than 95 % of the target volume was

covered by 95 % of the prescribed dose (Figure 8). To clinically evaluate the coverage of the
superficial chest wall, the 3 mm evaluation structure was observed on a dose volume histogram
(DVH) and the maximum dose to the structure was examined (Figure 9). In the VMAT DVH
evaluation; both patients received the prescription dose of 50.4 Gy or higher, except Patient 2s
plan with no bolus receiving the dose of 50.35 Gy. In all of the HT treatment plans, the 3 mm
evaluation structure received the prescription dose or greater. Further information was gathered
from Patient 1 and 2 of the HT plans.
Conclusion
The results of this case study demonstrated all techniques provide adequate PTV chest
wall coverage of at least 95% of the volume being covered by 95% of the prescribed dose. The
findings also concluded that proper superficial dose coverage was met with all bolus techniques
for the HT patient plans and all of the VMAT plans with the exception of the no bolus plan for
Patient 2. Patient 2s VMAT plan with no bolus received a maximum superficial dose of 50.35
Gy to the evaluation structure. This dose could be considered clinically acceptable differing
from the prescription only 0.09%. The TLDs support the dosimetric data by validating that two
of the HT plans, 5 mm bolus and no bolus, were clinically acceptable.
The results of this case study demonstrated that bolus is not required to provide proper
skin dose when using HT and VMAT treatment techniques for chest wall irradiation. There are
noted advantages of no bolus plans in comparison to bolus plans. One of the benefits of treating
without bolus is eliminating the uncertain reproducibility of bolus placement throughout the
course of the patients treatment. Typical bolus placement can vary day to day, especially when
different radiation therapists place the bolus. Air pockets can form by improper bolus to skin
contact on an uneven contour. Treatment with bolus is dependent on the daily variability of a
moveable object and can affect the dose distribution. Multiple uncertainties can be eliminated
when bolus is not used.
This case study only included 4 patients, 2 patients for VMAT and 2 patients for HT;
additional research should include additional patients using both HT and VMAT techniques. In
order to obtain additional support for superficial dose measurements, TLDs should be used to
read the superficial dose in all plans. Future research should also provide information using
VMAT plans with flattening free filter (FFF) beams to better compare with the HT plans with
FFF beams. Using the FFF beam eliminates beam hardening, which could provide more low

energy photons reaching superficial tissues. Using a FFF beam may explain why HT planning
proved to be easier to obtain superficial coverage compared to the VMAT planning. Therefore, a
proper bolus technique should be identified before institutions start integrating IMRT planning as
the primary treatment option for chest wall patients.

References
1. Ban KA, Godellas CV. Epidemiology of breast cancer. Surg Oncol Clin N Am.
2014;23(3):409-422. http://dx.doi.org/10.1016/j.soc.2016.03.011
2. Tieu MT, Graham P, Browne L, Chin YS. The effect of adjuvant postmastectomy
radiotherapy bolus technique in local recurrence. Int J Radiat Oncol Biol Phys.
2011;81(3):165-171. http://dx.doi.org/10.1016/j.ijrobp.2011.01.002
3. Blitzblau RC, Horton JK. Treatment planning technique in patients receiving
postmastectomy radiation therapy. Pract Radiat Oncol. 2013;3(4):241-248.
http://dx.doi.org/10.1016/j.prro.2012.09.004
4. Ordonez-Sanz C, Bowles S, MacDougall ND. A single plan solution to chest wall
radiotherapy with bolus? BJR Suppl. 2014;87:1-9. http://dx.doi.org/10.1259/bjr.20140035
5. Miescke, A. Bolus in radiation therapy: The versatility of water. Radiat Therap. 2016;
25(1):22-27.
6. Hsu SH, Roberson PL, Chen Y, Marsh RB, Pierce LJ, Moran JM. Assessment of skin
dose for breast chest wall radiotherapy as a function of bolus material. Phys Med Biol.
2008;53(10):2593-2606. http://dx.doi.org/10.1088/0031-9155/53/10/010
7. Nichols GP, Fontenot JD, Gibbons JP, Sanders ME. Evaluation of volumetric modulated
arc therapy for postmastectomy treatment. Radiat Oncol. 2014;9(66);1-8.
http://dx.doi.org/10.1186/1748-717x-9-66
8. Yang B, Wei, X, Zhao Y, Ma CM. Dosimetric evaluation of integrated IMRT treatment of
the chest wall and supraclavicular region for breast cancer after modified radical
mastectomy. Med Dosim. 2014;39(2):185-189.
http://dx.doi.org/10.1016/j.meddos.20113.12.008

Figures

Figure 1. The red arrows illustrate the posterior block used for the HT planning process to block
beams from entering and exiting in the patients posterior region.

Figure 2. The ring planning structures used in the HT planning process to force dose into the
target area instead of the normal tissue are located above. The blue ring represents the HDRing
and the yellow represents the LDRing.

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Figure 3. Gantry rotation for VMAT treatment planning. Four partial arc rotations represented,
two counter clockwise and two clockwise, with complimenting collimator settings.

Figure 4. Collimator jaw position representing the maximum x jaw travel of 15 cm for each arc
rotation.

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Figure 5. The light blue structure represents the superficial evaluation structure that was
retracted 3 mm off the body contour within the target area only.

Figure 6. The figure illustrates the TLD results from HT patient 2 with no bolus and a planned
fraction dose of 180 cGy. The locations of the TLDs were also listed.

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Figure 7. The figure illustrates the TLD results from HT patient 1 with 5mm of bolus and a
planned fraction dose of 180cGy. The locations of the TLDs on the patient were also listed.

95.25%
95.54%

Patient 1_HT

99.56%
99.57%
99.46%
99.75%

Patient 2_HT
Patient

98.44%

Patient 1_VMAT

99.88%
99.85%
99.80%
99.90%

Patient 2_VMAT
92%

97.50%

93%

94%

95%

96%

97%

98%

99%

100% 101%

Tumor Volume Receiving 95% Prescribed Dose

No Bolus

0.5cm Bolus

1.0 cmBolus

Figure 8. The PTV_eval chest wall was examined at 95% of the target volume receiving 95% of
the prescribed dose. This figure illustrates the volume of the target chest wall of each treatment
plan that received 95% of the prescribed dose (47.88 Gy).

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5449

Patient 1_HT

5533
5622
5446

Patient 2_HT

5305
5399

Patient

5722

Patient 1_VMAT

5573
5125
5237
5278

Patient 2_VMAT
4600

5035

4800

5000

5200

5400

5600

Maximum Skin Dose in cGy

No Bolus

0.5cm Bolus

1.0 cmBolus

Figure 9. Maximum skin dose comparison for VMAT and HT treatment plans per bolus
thickness.

5800