1

A Comparison of Radiation Dermatitis in Patients Receiving Chestwall Irradiation Using

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

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; Nishele Lenards, PhD., CMD, R.T.(R)(T),
FAAMD; Alyssa Olson, MS, R.T.(T), CMD

Medical Dosimetry Program at the University of Wisconsin, La Crosse, WI

ABSTRACT
The purpose of this study was to examine the radiation dermatitis produced by 2 differing
applications of tissue equivalent bolus (TEB). The continued prevalence of radiation dermatitis
found in radiotherapy treatment of chestwall patients has become an expected side effect.1 In
order to better understand how to manage this side effect, a comparison study of different TEB
thickness and frequency is required. The researchers analyzed a traditional advanced breast
cancer treatment method to determine if a case for standardization of TEB application is
warranted. Patient data was obtained from 2 facilities, with 23 patients treated with 3 mm bolus
daily compared with 20 patients treated with 5 mm bolus every other day. The radiation dose,
prescription, and field arrangement design were identical in each case to ensure an accurate
comparison. The researchers found that there was no statistically significant difference in
radiation dermatitis between the 2 methods by conducting a two-way repeated ordinal
cumulative mixed regression statistical analysis that resulted in a p-value of 0.368. However,
this may have been due to an inadequate sample size. A larger patient sample size could be
utilized in the future to better verify if one TEB approach has a significant difference over the
other.

Keywords: bolus, chestwall, radiation dermatitis, skin toxicity, breast cancer, post-mastectomy
radiation therapy

Introduction
Breast cancer is one of the most common forms of cancer, affecting roughly one in eight
women.1 The radiation oncology community is continually searching for the most effective
treatment method for this disease. The goal of radiation therapy is to deliver the prescription dose
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to the affected area while limiting adverse side effects. One effective technique in treating
advanced stage breast cancer is post-mastectomy radiation therapy (PMRT). For this regimen,
patients undergo a mastectomy prior to radiation treatments. This surgical procedure extracts as
much of the tumor as possible. Upon completion of the surgery, radiation is administered to
eradicate any remaining cancerous cells.
Historically, PMRT has utilized a tangential beam arrangement. With an appropriate
energy, this method delivers a prescribed dose of radiation to the chestwall, soft tissue, local skin
borders, and any involved lymph nodes. These include the supraclavicular, axillary lymph node
levels 1-3, and internal mammary nodes.2 The curvature of the chestwall and size of the body
habitus can create a challenge for radiotherapy treatment planning.2,3 The frequently used photon
beams reach peak effectiveness at a depth which can result in an under-dosage of the skin
surface. This, in turn, poses a risk for local 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.12,13 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.
While increasing the skin dose is important for adequate treatment, it can also cause
unfortunate side effects. Radiation dermatitis occurs when the skin is exposed to high doses of
radiation. Since bolus is designed to treat the skin surface, this is a common side effect of PMRT
patients. Each patient is subject to varying levels of radiation dermatitis depending upon the
location of their prescribed treatment volume, size of their body habitus, and the thickness and
frequency of bolus used.9-11 The challenge for physicians is deciding the proper amount of bolus
which will sufficiently distribute dose while limiting adverse skin reactions.
The researchers in this study focused 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 was to determine if one method produced less radiation dermatitis in patients
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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.

Methods and Materials

Patient Selection
This 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. Between the 2
facilities, 17 women had chest wall reconstruction, while 26 women left their post-surgery chest
wall unaltered. More specifically, Facility 1 had 20 patients with unaltered chest walls, while
Facility 2 had 6.
At Facility 1, 23 patients were scanned using a GE large bore CT scanner, with 2.5 mm
slice thickness. These patients were positioned with a breast angle board and a knee sponge. At
Facility 2, 20 patients were scanned with a Philips large bore CT, using a slice thickness of 3
mm. These patients were positioned on a wing board with both arms above their head, holding
onto hand pegs, and a knee sponge.
Contouring
For each patient, the physician delineated a clinical target volume (CTV), planned target
volume (PTV), and the supraclavicular nodal volume. The CTV was designed to encompass the
surgical bed, while the supraclavicular volume denoted where the supraclavicular lymph nodes
were found. An additional volume was also created to include the axillary nodes, levels 1-3.
Based on the size of the patient’s CTV, custom margins were applied to create a PTV structure.
The heart, esophagus, and both lungs were contoured by the medical dosimetrist. All target and
organs at risk (OAR) were contoured per the consensus definition provided by the Radiation
Therapy Oncology Group (RTOG) Breast Cancer Atlas.14
Treatment Planning
All the patients chosen for this study were treated with a 3-field technique, consisting of 2
tangents and a supraclavicular field. For consistency purposes, the tangential fields were treated
with 6 MV energy photon beams, while the supraclavicular field utilized either 15 MV or mixed
energy photon beams. Facility 1 data focused on the use of 3 mm bolus daily, while Facility 2
data focused on 5 mm bolus every other day.
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The participating facilities in this research study used 2 different treatment planning
systems (TPS). Facility 1 used Eclipse while Facility 2 used Pinnacle. All patients in this study
were treated using a mono-isocentric technique consisting of 2 opposing tangents and an anterior
oblique supraclavicular field. Each patient was treated with 6 MV photon beams for the tangent
fields and variable energies for the supraclavicular field, depending on patient anatomy.
The borders for both the tangents and supraclavicular field were designed to include the
entire PTV, the axillary nodal levels 1-3, and supraclavicular lymph nodes. At the time of
simulation, the physicians placed radiopaque wiring to define the intended treatment borders of
the patient’s chest wall. These borders were then used in conjunction with RTOG protocols to
create the appropriate field dimensions.
The treatment field borders used in this study were based on RTOG protocols.14 The
medial tangent border was placed at patient midline with the lateral boundary 2 cm beyond the
pre-existing breast tissue. The superior tangent edge matched the inferior border of the
supraclavicular field. Finally, the inferior tangential border was placed 2 cm below the
inframammary fold.
The borders for the supraclavicular field were different than those used for the tangent
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.
To maintain a baseline from which reliable conclusions could be drawn, patients
examined in this study received the same radiation dose. Each patient had a prescription of 200
cGy daily, for 25 fractions, for a total dose of 5,000 cGy. For both facilities, the physicians
required 100% of the PTV and nodal volumes to receive 90-95% of the 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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Results
The intent of this study was to analyze radiation dermatitis and compare the varying
effects of using 3 mm bolus daily versus 5 mm bolus every other day. The results gathered
displayed minor variations in the radiation dermatitis measurements taken between the 2
facilities. For the first week of treatment, 91% of patients from facility one reported no skin
reaction with 85% of patients from facility two giving the same response. The second week of
treatment displayed a small variation with 30% of facility one and 55% of facility two reporting
no skin reaction. However, 70% of facility one scored a one on the radiation dermatitis index
with only 45% of facility two giving the same score.
During the third week of treatment, a noticeable difference was found. Only 4% of
Facility 1 patients experienced no skin reaction, whereas 20% of Facility 2 patients had no
reaction. This coincided with 96% of Facility 1 patients scoring a 1 on the radiation dermatitis
index, where only 70% of Facility 2 patients scored a 1. However, this did not materialize into
anything significant in the subsequent weeks. During week 4, 83% of Facility 1 patients scored a
1, compared with 70% for Facility 2. For the same week, 17% of Facility 1 patients scored a 2,
whereas 25% of Facility 2 did.

Discussion
A 5-week radiation dermatitis analysis was completed for 23 patients who underwent 3
mm bolus application daily, and 20 patients who underwent 5 mm bolus application every other
day. Facility 1 evaluated the use of 3 mm bolus, while Facility 2 assessed the use of 5 mm bolus.
The scale used to measure each patient’s radiation dermatitis ranged from 0 to 4; 0 – No reaction,
1 – Faint erythema or dry desquamation, 2 – Moderate to brisk erythema or patchy moist
desquamation, mostly confined to skin folds and creases; or moderate edema, 3 – Confluent
moist desquamation > 1.5 cm diameter and not confined to skin folds; pitting edema, 4 – Skin
necrosis or ulceration of full-thickness dermis; may include bleeding not induced by minor
trauma or abrasion.15 The treating physicians determined that no patients exceeded a 2 on the
scale during the 5-week examination. Given this fact, dermatitis levels above 2 were not included
in the results. However, 1 patient in Facility 1 had their treatment terminated at 4,800 cGy due
to radiation dermatitis. For this analysis the supraclavicular field was not taken into
consideration as a contributing factor in the degree of radiation dermatitis. Additionally,
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Elastogel and Superflab were considered equivalent bolus material and no difference in density
was accounted for when collecting the radiation dermatitis data from the patient.
The data collected was analyzed using a two-way repeated ordinal cumulative mixed
regression model to test for the difference in radiation dermatitis from Facilities 1 and 2. When
testing for a 5% level of significance the model determined there was not a significant difference
between Facilities 1 and 2 by earning a p-value of 0.368.16 Results are displayed in graph figures
1 and 2, visually representing no significant differences.
No observable trend could be found by comparing the 2 facilities’ radiation dermatitis
data. Instead, a “seesaw effect” was detected with 1 facility’s radiation dermatitis scores higher 1
week, and the other the next. This could be because the 2 treatment methods actually result in
the same relative skin toxicity. While the researchers could not find a consistent trend between
the facilities, others may note different outcomes.

Conclusion
In conclusion, there appears to be little difference in skin toxicity between using 3 mm
bolus every day and 5 mm bolus every other day. This information should aid physicians and
dosimetrists in creating treatment plans. Medical professionals can rest assured that, regardless of
the technique they choose, the subsequent skin reactions will remain unaffected.
This study achieved its goal by providing results for the analysis of 2 different treatment
methods and their effects on skin toxicity. One possible limitation of this study was the small
patient population size used. A larger and more diverse study sample size may be necessary to
obtain more substantial results. If complemented by a study of greater size and scope, this could
inform physicians that there is truly no risk of further skin damage by selecting 1 TEB method
over another.
The primary objective of radiation therapy is to provide quality treatments to patients
with minimal side effects. Skin reactions can lead to discomfort and pain for those patients that
experience them. By continuing to study this aspect of radiation oncology, care can be improved
for patients and an optimal technique can be recommended.
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We would like to express our thanks to Dr. David Reineke, Thomas Theisen, and Carsten Hiltgen
of the UWL Statistical Consulting Center for their contributions to the statistical analysis and
interpretation of statistical results
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radiotherapy as a function of bolus material. Phys Med Biol. 2008;53:2593-2606.
https://dx.doi.org/10.1088/0031-9155/53/10/010

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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):E3-E3.
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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.
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https://www.rpdinc.com/elasto-gel-05cm-thick-x-30cm-square-1716.html. Accessed
September 16, 2018.
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Figures

Figure 1. Radiation dermatitis progression, grade 0 to 2, for 3 mm daily at Facility 1 and 5 mm

every other day at Facility 2.
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Figure 2. Estimated marginal mean radiation dermatitis level by week.