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

Abstract
Introduction: The purpose of this study was to examine the radiation dermatitis produced by 2
differing applications of tissue equivalent bolus (TEB). The prevalence of radiation dermatitis
found in radiotherapy treatment of chestwall patients required a TEB comparison to determine if
differing frequency of TEB impacted the severity of skin toxicity. This case study analyzed a
traditional advanced breast cancer treatment method to determine if a case for standardization of
TEB application is warranted.
Case Description: Patient data was obtained from 2 facilities and patients treated with 3 mm
bolus every day were compared with those using 5 mm bolus every other day. The radiation dose
prescription and field arrangement design were identical in each case to ensure an accurate
comparison.
Conclusion: The study found that there was little difference in radiation dermatitis between the
2 methods. However, this may have been due to an inadequate sample size. A larger patient
population could be utilized in the future to better verify if one TEB approach has a statistically
significant difference than the other.
Key words: bolus, chestwall, radiation dermatitis

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 treatment is the management of side effects, which can include minimizing
radiation dermatitis. Before a patient receives radiation therapy treatment, it is common for
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patients with breast cancer to undergo a surgical procedure. Depending on the severity and extent
of the cancer, 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. One effective technique in
treating advanced stage breast cancer is post-mastectomy radiation therapy (PMRT).
Historically, PMRT utilizes an oblique beam arrangement with an appropriate energy to deliver a
prescribed dose of radiation to the chestwall, soft tissue, local skin borders, axillary lymph nodes
levels 1-3, as well as any lymph nodes of concern such as: supraclavicular, and internal
mammary; and any remaining breast tissue as delineated by the treating physician.2 The
curvature of the chestwall, the size of the body habitus, and varying densities in the bone, lung
and soft tissue can create a challenge 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 recurrence.2,3 In order to counteract the loss of prescription dose to the skin surface in
the treatment area, a TEB is often used.2-5
Tissue equivalent bolus may be composed of various materials including SuperStuff,
Elasto-Gel and Superflab14-16. 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 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
This case 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
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.
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Case Description

Patient Selection & Setup

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. Between the 2
facilities, 17 women had chestwall reconstruction, while 26 women left their post-surgery
chestwall unaltered. More specifically, facility 1 had 20 patients with unaltered chestwalls, while
Facility 2 had 6). Bolus application can be challenging when conforming it to the patients
chestwall reconstruction without leaving small air gaps. When there is an air gap in the bolus,
this can cause the patient to have a higher skin dose, causing a higher likelihood to develop
radiation dermatitis.
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 were scanned with a Philips large bore CT, using a slice thickness of 3 mm. These
patients were positioned on a wingboard with both arms above their head, holding onto hand
pegs. A knee sponge was used and a mattress was placed under the hips for comfort.
All the patients chosen for this study were treated with a 3-field technique of 2 tangents
with a supraclavicular field. Only patients with their chestwall and supraclavicular lymph nodes
treated were chosen for this study. 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. Facility 1 data focused on the use of 3 mm bolus daily while Facility 2
data focused on 5 mm bolus every other day.
Target Delineation
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. Based on the size of the patient’s GTV, custom margins were applied to
create a PTV structure. The heart, esophagus, and both lungs were contoured by the medical
dosimetrist.
Treatment Planning
The participating facilities in this research study used 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 obliques and a
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supraclavicular field. Each patient was treated with 6 MV photon beams for the oblique fields
and variable energies for the supraclavicular field depending on patient anatomy.
The treatment field borders used in this study were based on Radiation Therapy
Oncology Group (RTOG) protocols.12 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 oblique
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 tangents and supraclavicular fields 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 chestwall. These borders were then used in conjunction with RTOG protocols to
create the appropriate field dimensions.
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 200 cGy daily,
for 25 fractions to a total dose of 5,000 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.
Plan Analysis and Evaluation
A 5-week radiation dermatitis analysis was completed for 23 patients who underwent the
3 mm bolus q.d. protocol and the 20 patients who underwent the 5 mm bolus q.i.d. protocol.
Facility 1 evaluated the use of 3 mm bolus q.d. protocol while Facility 2 evaluated the use of 5
mm bolus q.i.d. protocol found in Table 1. 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
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creases; or moderate edema.13 No patients exceeded a 2 on the scale during the 5-week
examination. 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 factor in the radiation dermatitis. Additionally, 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.
Week 1 resulted in 91% of Facility 1 patients and 85% of Facility 2 patients having no
reaction, 9 % of Facility 1 patients and 15% of Facility 2 scoring a 1 and no scores reaching 2.
There were no major discrepancies between the 2 facilities in the first week. Due to the data not
appearing significantly different no statistical analysis was warranted.
Week 2 resulted in 30% of Facility 1 patients and 55% of Facility 2 patients having no
reaction, 70 % of Facility 1 patients and 45% of Facility 2 scoring a 1 and no scores reaching 2.
There were no major disparities between the two facilities in the second week as well. However,
due to the data not appearing significantly different no statistical analysis was warranted.
Week 3 resulted in 4% of Facility 1 patients and 20% of Facility 2 patients having no
reaction, 96 % of Facility 1 patients and 70% of Facility 2 scoring a 1 and 0% of Facility 1
patients and 10% of Facility 2 patients scoring a 2. There were no major disparities between the
two groups in the third week as well but it is noted that Facility 2 progresses at a faster rate but
with less quantity. However, due to the data not appearing significantly different no statistical
analysis was warranted.
Week 4 resulted in 0% of Facility 1 patients and 5% of Facility 2 patients having no
reaction, 83 % of Facility 1 patients and 70% of Facility 2 scoring a 1 and 17% of Facility 1
patients and 25% of Facility 2 patients scoring a 2. There were no major disparities between the
two facilities in the fourth week as well. Due to the data not appearing significantly different no
statistical analysis was warranted.
Week 5 resulted in 0% of patients having no reaction, 22 % of Facility 1 patients and
35% of Facility 2 scoring a 1 and 78% of Facility 1 patients and 65% of Group 2 patients scoring
a 2. There were no major disparities between the two groups in the final week. Statistically
speaking a disparity does not exist that calls for a standardized statistical analysis. Future studies
may require a greater sample size to achieve a disparity great enough to justify a statistical
analysis to carry out the appropriate quantifiable tests. However, the greatest disparity between
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the facilities occurred during week 3 with Facility 1 patients having 4% experience no reaction
while 20% of Facility 2 experienced no reaction and 96% of Facility 1 patients and only 70% of
Facility 2 patients scored a 1.

Conclusion
The intent of this study was to analyze radiation dermatitis and compare the varying
effects of using 3 mm bolus q.d. with 5 mm bolus q.o.d. The results gathered displayed little
variation in the skin toxicity measurements taken between the 2 facilities. During the third week
of treatment, a noticeable difference was found. Only 4% of Facility 1 patients experienced no
skin reaction where 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.
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 due to the fact that the2 treatment methods truly
result in the same relative skin toxicity. While this study could not find a consistent trend
between the research facilities, other studies may note different outcomes. It would be beneficial
to establish a universal radiation dermatitis scorecard that could be used by various centers that
include visual references to help standardize the effort. Results would then be consistent and
conclusions could be drawn by the data gathered. A larger and more diverse study population
may be necessary to obtain more substantial results. In the end, this study displayed a minor, if
non-existent, difference in radiation dermatitis between the 2 treatment methods. If
complemented by a study of greater size and scope, this could inform physicians that there is no
risk of further skin damage by selecting 1 TEB method over another.
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4. Andic F, Ors Y, Davutoglu R, et al. Evaluation of skin dose associated with different
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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
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Tables
Table 1. Radiation dermatitis progression analysis, grade 0 to 4, for 3 mm q.d. protocol (Facility
1) and 5 mm q.o.d. protocol (Facility 2)
Week 1 Week 2 Week 3 Week 4 Week 5

0 1 2 0 1 2 0 1 2 0 1 2 0 1 2
F1 91% 9% 0% 30% 70% 0% 4% 96% 0% 0% 83% 17% 0% 22% 78%

F2 85% 15% 0% 55% 45% 0% 20% 70% 10% 5% 70% 25% 0% 35% 65%