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Purpose: This study aims to investigate the effects of chest wall bolus in intensity-modulated radiotherapy (IMRT) technology on clinical outcomes for post-mastectomy breast cancer patients. Materials and methods: This retrospective study included patients with invasive carcinoma ((y)pT0-4, (y)pN0-3) who received photon IMRT after mastectomy at the Affiliated Hospital of Qingdao University from 2014 to 2019. The patients were divided into two groups based on whether they received daily bolus application or not, and the baseline characteristics were matched using propensity score matching (PSM). Cumulative incidence (CI) of local recurrence (LR), locoregional recurrence (LRR), overall survival (OS) and disease-free survival (DFS) were evaluated with a log-rank test. Acute skin toxicity and late radiation pneumonia was analyzed using chi-square test. Results: A total of 529 patients were included in this study, among whom 254 (48%) patients received bolus application. The median follow-up time was 60 months. After matching, 175 well-paired patients were selected. The adjusted 5-year outcomes (95% confidence interval) in patients treated with and without bolus were, respectively: CI of LR 2.42% (0.04–4.74) versus 2.38% (0.05–4.65), CI of LRR 2.42% (0.04–4.74) versus 3.59% (0.73–6.37), DFS 88.12% (83.35–93.18) versus 84.69% (79.42–90.30), OS 94.21% (90.79–97.76) versus 95.86% (92.91–98.91). No correlation between bolus application and skin toxicity (P = 0.555) and late pneumonia (P = 0.333) was observed. Conclusions: The study revealed a low recurrence rate using IMRT technology. The daily used 5 mm chest wall bolus was not associated with improved clinical outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To present the commissioning process of a low‐cost solution for directly 3D printed flexible patient specific bolus. Methods: The 3D printing solution used in this study consisted of a resin stereolithography 3D printer and a flexible curing resin. To test the dimensional accuracy of the 3D printer, rectangular cuboids with varying dimensions were 3D printed and their measured dimensions were compared to the designed dimensions. Percent Depth Dose (PDD) profiles were measured by irradiating film embedded in a 3D printed phantom made of the flexible material. A CT of the phantom was acquired and used to replicate the irradiation setup in the treatment planning system. PDDs were calculated for both the native HU of the phantom, and with the phantom HU overridden to 300 HU to match its physical density. Dosimetric agreement was characterized by comparing calculated to measured depths of R90, R80, and R50. Upon completion of the commissioning process, a bolus was 3D printed for a clinical case study for treatment of the nose. Results: Dimensional accuracy of the printer and material combination was found to be good, with all measured dimensions of test cuboids within 0.5 mm of designed. PDD measurements demonstrated the best dosimetric agreement when the material was overridden to 300 HU, corresponding to the measured physical density of the material of 1.18 g/cc. Calculated and measured depths of R90, R80, and R50 all agreed within 1 mm. The bolus printed for the clinical case was free from defects, highly conformal, and led to a clinically acceptable plan. Conclusion: The results of the commissioning measurements performed indicate that the 3D printer and material solution are suitable for clinical use. The 3D printer and material combination can provide a low‐cost solution a clinic can implement in‐house to directly 3D print flexible bolus. [ABSTRACT FROM AUTHOR]

Objective(s): The aim of this study was to determine the entrance skin dose distribution for breast cancer patients who undergo radiotherapy in the presence of bolus containing gold and Fe3O4 nanoparticles to evaluate and compare the changes in dose distribution. Materials and Methods: Gold and Fe3O4 nanoparticles can increase the rate of photoelectric, Compton, and pair production absorption of x-ray photons. Nanoparticles were simulated in the bolus, over the skin of a breast phantom, by the exertion of MCNPX Monte Carlo code. The skin dose was also experimentally measured by using a bolus that contained homogeneously distributed Fe3O4 nanoparticles on the surface of a slab phantom and an advanced Markus chamber. Results: A significant skin dose enhancement was obtained for the case that 25 nm gold and Fe3O4 nanoparticles with 3% concentration were uniformly distributed in the bolus. However, increased concentration of nanoparticles in the bolus will increase the skin dose. Conclusion: It is concluded that using nanoparticles in the bolus leads to a significant skin dose enhancement for 6 MV x-ray photons. Furthermore, this study suggested that, less thick blouses may provide the same dose distribution. [ABSTRACT FROM AUTHOR]

Introduction: Polylactic acid (PLA) is a promising material for customised bolus 3D‐printing in radiotherapy, however variations in printing techniques between external manufacturers could increase treatment uncertainties. This study aimed to assess consistency across various 3D‐printed PLA samples from different manufacturers. Methods: Sample prints of dimensions 5 × 5 × 1 cm with 100% infill were acquired from multiple commercial 3D‐printing services. All samples were CT scanned to determine average Hounsfield unit (HU) values and physical densities. The coefficient of equivalent thickness (CET) was obtained for both photons and electrons and dose attenuation compared to TPS calculations in Elekta Monaco v5.11. Results: Some samples showed warped edges up to 1.5 mm and extensive internal radiological defects only detectable with CT scanning. Physical densities ranged from 1.06 to 1.22 g cm−3 and HU values ranged from −5.1 to 221.0 HU. Measured CET values varied from 0.95 to 1.17 and TPS dose calculations were consistent with the variation in CET. Electron R50 and R90 shifted by up to 2 mm for every 1 cm of printed bolus, a clinically significant finding. Photon surface dose varied by up to 3%, while depth doses were within 1%. Conclusions: 3D‐printed PLA can have considerable variability in density, HU and CET values between samples and manufacturers. Centres looking to outsource 3D‐printed bolus would benefit from clear, open communication with manufacturers and undertake stringent QA examination prior to implementation into the clinical environment. [ABSTRACT FROM AUTHOR]

Background: Malignancies of the head and neck region, encompassing cutaneous, mucosal, and sarcomatous histologies, are complex entities to manage, comprising of coordination between surgery, radiation therapy, and systemic therapy. Malignancies of the posterior scalp are particular challenging to treat with radiation therapy, given its irregular contours and anatomy as well as the superficial location of the target volume. Bolus material is commonly used in radiation therapy to ensure that the dose to the skin and subcutaneous tissue is appropriate and adequate, accounting for the buildup effect of megavoltage photon treatment. The use of commercially available bolus material on the posterior scalp potentially creates air gaps between the bolus and posterior scalp. Case presentations: In this report, we created and utilized a custom 3D-printed integrated bolus and headrest for 5 patients to irradiate malignancies involving the posterior scalp, including those with cutaneous squamous cell carcinoma, melanoma, malignant peripheral nerve sheath tumor, and dermal sarcoma. Treatment setup was consistently reproducible, and patients tolerated treatment well without any unexpected adverse effects. Conclusions: We found that the use of this custom 3D-printed integrated bolus/headrest allowed for comfortable, consistent, and reproducible treatment set up while minimizing the risk of creating significant air gaps and should be considered in the radiotherapeutic management of patients with posterior scalp malignancies. [ABSTRACT FROM AUTHOR]

A 3D-printed bolus is being developed to deliver accurate doses to superficial cancers. In this study, flexible thermoplastic filaments, specifically PLA, TPU, PETG, and HIPS, were fabricated into boluses and then compared to commercial bolus for the variation of the dose elevation region of photon beams. The experimental results indicate that the maximum dose depth is similar, and the consistent trend of the percentage depth dose confirms the potential usage as a build-up bolus. • We compared boluses made of thermoplastic filaments such as PLA, TPU, PETG, and HIPS, utilized in 3D printing, to commercial boluses in terms of dose-elevation region variations. • We identified consistent trends in both maximum dose depth(D max) and percentage depth dose. • Fabrication of patient-specific boluses will aid in reducing foreign body sensations experienced by patients and enable accurate dose distribution by conforming closely to the body surface. [ABSTRACT FROM AUTHOR]

Purpose: Use of standard‐of‐care radiation therapy boluses may result in air‐gaps between the target surface and bolus, as they may not adequately conform to each patient's unique topography. Such air‐gaps can be particularly problematic in cases of superficial pelvic tumor radiation, as the density variation may result in the radiation delivered to the target site being inconsistent with the prescribed dose. To increase bolus fit and thereby dose predictability and homogeneity, we designed and produced a custom silicone bolus for evaluation against the clinical standard. Methods: A custom bolus was created for the pelvic regions of both an anthropomorphic phantom and a pelvic patient with squamous cell carcinoma of the penile shaft. Molds were designed using computed tomography (CT) scans, then 3D‐printed and cast with silicone rubber to yield the boluses. Air‐gap measurements were performed on custom and standard‐of‐care Superflab gel sheet boluses by analyzing total volume between the bolus and target surface, as measured from CT scans. Therapeutic doses of radiation were delivered to both boluses. Radiation dose was measured and compared to the expected dose using nine optically stimulated luminescent dosimeters (OSLDs) placed on the phantom. Results: Mean air‐gap volume between the bolus and phantom was decreased from 314 ± 141 cm3 with the standard bolus to 4.56 ± 1.59 cm3 using the custom device. In the case of the on‐treatment patient, air‐gap volume was reduced from 169 cm3 with the standard bolus to 46.1 cm3 with the custom. Dosimetry testing revealed that the mean absolute difference between expected and received doses was 5.69%±4.56% (15.1% maximum) for the standard bolus and 1.91%±1.31% (3.51% maximum) for the custom device. Areas of greater dose difference corresponded to areas of larger air‐gap. Conclusions: The custom bolus reduced air‐gap and increased predictability of radiation dose delivered compared to the standard bolus. The custom bolus could increase the certainty of prescribed dose‐delivery of radiation therapy for superficial tumors. [ABSTRACT FROM AUTHOR]

Aims: To retrospectively evaluate the quality of fit of 3D printed bolus over four different treatment sites to determine whether certain sites favor a 3D printed approach and if the quality of fit changes over the course of treatment. Materials and methods: A retrospective analysis of the first 60 cases treated using 3D printed bolus in our radiotherapy center was undertaken. All boluses were printed using flexible thermoplastic polyurethane (TPU) material. We developed a system of rating the quality of fit using four quality categories. The analysis of 60 patients consisted of a review of a total 627 treatment fractions for head and neck (H&N), scalp, pelvis, and extremity treatment sites. Results: Out of 627 fractions evaluated, 75.1% were rated either "good" or "excellent", 20.6% were rated as "acceptable" and 4.3% were rated "poor". H&N, scalp, and extremity treatment regions were found to favor a 3D printed approach. However, pelvis cases had a higher proportion of "acceptable" and "poor" ratings. Trend analysis showed no notable change in the quality of 3D printed bolus fit over the course of treatment, except for pelvis cases which tended to change categories more than other treatment sites. Conclusion: This evaluation demonstrates that 3D printed bolus, created using semi‐flexible materials such as TPU, is an effective and practical bolus choice for radiotherapy. In particular, using a 3D printed approach for H&N, scalp, and extremities was found to have a highly conformal fit. [ABSTRACT FROM AUTHOR]

Background: The use of boluses for radiation therapy is very necessary to overcome the problem of sending inhomogeneous doses in the target volume due to irregularities on the surface of the skin. The bolus materials for radiation therapy need to be evaluated. Objective: The present study aims to evaluate some handmade boluses for megavoltage electron and photon radiation therapy. Several dosimetric properties of the synthesized boluses, including relative electron density (RED), transmission factor, mass attenuation coefficient, percentage depth dose (PDD), and percentage surface dose (PSD) were investigated. Material and Methods: In this experimental study, we evaluated natural rubber, silicone rubber mixed either with aluminum or bismuth, paraffin wax, red plasticine, and play-doh as soft tissue equivalent. CT-simulator, in combination with ECLIPSE software, was used to determine bolus density. Meanwhile, Linear Accelerator (Linac) Clinac iX (Varian Medical Systems, Palo Alto), solid water phantom, and Farmer ionization chamber were used to measure and analyze of dosimetric properties. Results: The RED result analysis has proven that all synthesized boluses are equivalent to the density of soft tissue such as fat, breast, lung, and liver. The dosimetric evaluation also shows that all synthesized boluses have a density similar to the density of water and can increase the surface dose with a value ranging from 6-20% for electron energy and 30-50% for photon energy. Conclusion: In general, all synthesized boluses have an excellent opportunity to be used as an alternative tissue substitute in the surface area of the body when using megavoltage electron and photon energy. [ABSTRACT FROM AUTHOR]

Introduction: Bolus-type materials are needed in case of superficial lesions radiotherapy. This work determined the dosimetric accuracy of two commercial treatment planning systems (TPS) for calculating photon dose distribution in the presence of eXaSkin bolus. Material and Methods: Dose calculations were performed on collapsed cone convolution/superposition (CCC) and anisotropic analytical algorithm (AAA) using computed tomography (CT) images of heterogeneous CIRS phantom. EBT3 film was used to obtain percentage depth dose (PDD) curves and gamma index was utilized to compare the accuracy of the two algorithms. The passing rate of the global gamma index with the passing criterion of 3mm/3% as the standard criterion was considered 95% in this study. Results: Surface dose in PDD curves increased in the presence of 0.5 cm thick eXaSkin bolus. The passing rates of gamma index with standard passing criterion between AAA algorithm and EBT3 film measurements without and with bolus were 95% and 95.5%, respectively, while they were equal to 96% and 97.5% for CCC algorithm. Conclusion: There was a good agreement in dose calculation between AAA and CCC algorithms. Furthermore, eXaSkin bolus increased the surface dose by a factor of 25%. [ABSTRACT FROM AUTHOR]

In radiation therapy, a bolus is used to improve dose distribution in superficial tumors; however, commercial boluses lack conformity to patient surface leading to the formation of an air gap between the bolus and patient surface and suboptimal tumor control. The aim of this study was to explore 3D-printing technology for the development of patient-specific conformal 3D-printed devices, which can be used for the radiation treatment of superficial head and neck cancer (HNC). Two 3D boluses (0.5 and 1.0 cm thick) for surface dose build-up and patient-specific 3D phantom were printed based on reconstruction of computed tomography (CT) images of a patient with HNC. The 3D-printed patient-specific phantom indicated good tissue equivalency (HU = −32) and geometric accuracy (DSC = 0.957). Both boluses indicated high conformity to the irregular skin surface with minimal air gaps (0.4–2.1 mm for 0.5 cm bolus and 0.6–2.2 mm for 1.0 cm bolus). The performed dose assessment showed that boluses of both thicknesses have comparable effectiveness, increasing the dose that covers 99% of the target volume by 52% and 26% for single field and intensity modulated fields, respectively, when compared with no bolus case. The performed investigation showed the potential of 3D printing in development of cost effective, patient specific and patient friendly conformal devices for dose verification in radiotherapy. [ABSTRACT FROM AUTHOR]

The bolus is used to cover tumors in the shallow skin of cancer patients for a desired dose distribution in the high-energy radiotherapy. This research develops methods to improve the accuracy of bolus shaping by unfolding the human surface model for refolding. A surface segmentation method is proposed to separate a non-developable surface into a few pieces based on a clustering method to increase flattenability. In the segmentation process, a 3D surface model is embedded into a spectral space using a Laplacian matrix to combine the surface segmentation saliency and geometric characteristics. A smooth common boundary is designed based on clustering results to simplify the shape of each part. The 3D surface model is unfolded into 2D patches by the coordinate transformation and optimized using a mass-spring model. Case studies are conducted to verify the effectiveness of the proposed method in the bolus shaping. [ABSTRACT FROM AUTHOR]

We aimed to analyze the effects of printing parameters on characterization of three-dimensional (3D) printed bolus used in external beam radiotherapy. Two sets of measurements were performed to investigate the dosimetric and physical characterization of 3D-printed bolus at different printing parameters. In the first step, boluses were produced at different infill-percentages, infill-patterns and printing directions. Two-dimensional (2D) dose measurements were performed in Elekta Versa HD linear accelerator using 6 MV photon energy. Measured 2D dose maps for both printed and reference bolus materials were compared using the 2D gamma analysis method. Additionally, patient-specific bolus was produced with defined optimum printing parameters for anthropomorphic head and neck phantom. Then, point dose measurements were performed to evaluate the feasibility of printed bolus in clinical use. In the second step, physical measurements were carried out to evaluate the printing accuracy, the mean hounsfield unit (HU) value and the weight of 3D-printed boluses. According to our measurement, infill-percentage, infill-pattern and printing direction significantly changed the dosimetric and physical properties of the 3D-printed bolus independently. Maximum gamma passing rate at 1.5 and 5 cm depths were found as 93.8% and 98.8%, respectively, for 60% infill-percentage, sunglass fill infill-pattern and horizontal printing direction. The printing accuracy of the products was within 0.4 mm. Dosimetric and physical properties of the printed bolus material changed significantly with the selected printing parameters. Therefore, it is important to note that each combination of these printing parameters that will be used in the production of patient-specific bolus should be investigated separately. [ABSTRACT FROM AUTHOR]

There remains wide variation in the use of chest wall boluses for postmastectomy radiotherapy, which may result from the need for 2 treatment plans with the commonly used half-time tissue-equivalent 5-mm-thick bolus to achieve a full surface dose. To establish a bolus method requiring one treatment plan, we assessed the surface dose of a thinner daily bolus for all treatment fractions and compared it against the half-time 5-mm-thick bolus. In this basic study, we specifically investigated dosage achieved when using the following: (1) the existing bolus protocol, a half-time 5-mm-thick tissue-equivalent Clearfit bolus (Fujidenolo Inc., Aichi, JP); (2) no bolus; and (3) daily 1-, 2-, and 3-mm-thick Clearfit boluses at 4 and 6 MV photons. Dosimetric measurements were then taken in an anthropomorphic phantom to study the effect of each regimen on the surface doses, and the mean surface doses of the daily thinner boluses were compared with the existing bolus protocol by the Welch 2-sample t test. The mean surface doses for the existing bolus protocol, no bolus, and daily 1-, 2-, and 3-mm-thick boluses were 68% (range, 59% to 77%), 53% (41% to 66%), 73% (60% to 83%), 77% (66% to 87%), and 82% (75% to 91%) of the prescription dose at 4 MV, respectively; the corresponding values at 6 MV were 71% (63% to 79%), 50% (39% to 60%), 72% (56% to 83%), 81% (68% to 90%), and 89% (80 to 97%) of the prescription dose. The mean surface doses were comparable between the existing bolus protocol and the 1-mm-thick daily bolus at 4 and 6 MV. In conclusion, the mean surface dose of a 1-mm-thick bolus approximate that of a half-time 5-mm-thick bolus at 4 and 6 MV. As such, we have started a prospective clinical study on the safety and efficacy of a 1-mm-thick bolus for postmastectomy radiotherapy. [ABSTRACT FROM AUTHOR]

Background: The optimal chest wall bolus regimen for postmastectomy radiotherapy (PMRT) remains unknown. We aimed to prospectively evaluate the use of a 1-mm-thick daily tissue-equivalent bolus in patients who received PMRT using thermoluminescent dosimeters (TLDs) and skin toxicity assessment.Methods: Patients with a 1-mm-thick daily bolus during PMRT were prospectively enrolled at The Juntendo University Hospital. The surface dose was measured in vivo under the 1-mm-thick bolus on the chest wall. We assessed the acute skin toxicity weekly during PMRT, and 1, 2, 4, and 12 weeks after the completion of PMRT.Results: A total of 19 patients aged 32-79 years old received PMRT from July 2019 to January 2020. All patients completed the protocol treatment without interruptions, and the median follow-up was 32 weeks. In vivo dosimetry analysis revealed surface doses between 77 and 113% of the prescribed dose, with a mean of 92% of the prescribed radiation dose, and a standard deviation of 7% being delivered. Grade 2 dermatitis was found in 10 patients (53%), and Grade 3 dermatitis was found in one patient (5%). All cases of Grade 2 and 3 dermatitis were improved 4 weeks after PMRT. There were no cases of Grade 4 dermatitis and no chest wall recurrences during the treatment or follow-up period.Conclusions: Results confirmed the feasibility of using a 1-mm-thick daily bolus for PMRT, exhibiting an appropriate dose buildup and acceptable skin toxicity without treatment interruptions.Trial Registration: The University Hospital Medical Information Network Clinical Trials Registry, UMIN000035773 . Registered 1 July 2019. [ABSTRACT FROM AUTHOR]

Boluses characterize materials with an electromagnetic radiation attenuation coefficient similar to biological tissue and used to restrict the penetration of high energy photons and electrons used in radiotherapy for the treatment of superficial tumors. The development of new materials, mainly from sustainable biotechnological routes, will contribute to increase efficiency and expand the use of these technologies. The objective of this research was to develop the "proof of concept" regarding the use of the bacterial nanocellulose membrane (BNCm) as a bolus. For this purpose, BNCm were produced, purified and subjected to the physical–chemical characterization. The radiological density (RD) and radiation attenuation potential (RAP) of the BNCm were established and compared to a commercial bolus (CB). The moldability of BNCm was established and compared to the virtual bolus of dosimetric planning. The physical–chemical analysis demonstrated the constitution of a pure, highly hydrated, homogeneous and nanostructured network of cellulose fibers. BNCm showed superiority in relation to RD and similar RAP values when compared to CB. Moldability analysis showed a profile identical to a virtual bolus. The results validate the concept of using BNCm as a highly efficient biotechnological device, aligned with the idea of sustainability, as a bolus for use in radiotherapy. [ABSTRACT FROM AUTHOR]

Purpose: We developed a thermoset shape memory bolus (shape memory bolus) made from poly‐ε‐caprolactone (PCL) polymer. This study aimed to investigate whether the shape memory bolus can be applied to radiotherapy as a bolus that conformally adheres to the body surface, can be created in a short time, and can be reused. Methods: The shape memory bolus was developed by cross‐linking tetrabranch PCL with reactive acrylate end groups. Dice similarity coefficient (DSC) was used to evaluate shape memory characterization before deformation and after restoration. In addition, the degree of adhesion to the body surface and crystallization time were calculated. Moreover, dosimetric characterization was evaluated using the water equivalent phantom and an Alderson RANDO phantom. Results: The DSC value between before deformation and after restoration was close to 1. The degree of adhesion of the shape memory bolus (1.9%) was improved compared with the conventional bolus (45.6%) and was equivalent to three‐dimensional (3D) printer boluses (1.3%–3.5%). The crystallization time was approximately 1.5 min, which was clinically acceptable. The dose calculation accuracy, dose distribution, and dose index were the equivalent compared with 3D boluses. Conclusion: The shape memory bolus has excellent adhesion to the body surface, can be created in a short time, and can be reused. In addition, the shape memory bolus needs can be made from low‐cost materials and no quality control systems are required for individual clinical departments, and it is useful as a bolus for radiotherapy. [ABSTRACT FROM AUTHOR]

Purpose: This study was designed to evaluate skin dose in both VMAT and tangent treatment deliveries for the purpose of identifying suitable bolus use protocols that should produce similar superficial doses. Methods: Phantom measurements were used to investigate skin dose in chest wall radiotherapy with and without bolus for 3D and rotational treatment techniques. Optically stimulated luminescence dosimeters (OSLDs) with and without housing and EBT3 film were used. Superflab (3, 5, and 10 mm) and brass mesh were considered. Measured doses were compared with predictions by the Eclipse treatment planning system. Patient measurements were also performed and the bolusing effect of hospital gowns and blankets were highlighted. The effect of flash for VMAT plans was considered experimentally by using 2 mm couch shifts. Results: For tangents, average skin doses without bolus were 0.64 (EBT3), 0.62 (bare OSLD), 0.77 (jacketed OSLD), and 0.68 (Eclipse) as a fraction of prescription. For VMAT, doses without bolus were 0.53 (EBT3), 0.53 (bare OSLD), 0.64 (jacketed OSLD), and 0.60 (Eclipse). For tangents, the average doses with different boluses as measured by EBT3 were 0.99 (brass mesh), 1.02 (3 mm), 1.03 (5 mm), and 1.07 (10 mm). For VMAT with bolus, average doses as measured by EBT3 were 0.83 (brass), 0.96 (3 mm), 1.03 (5 mm), and 1.04 (10 mm). Eclipse doses agreed with measurements to within 5% of measurements for all Superflab thicknesses and within 15% of measurements for no bolus. The presence of a hospital gown and blanket had a bolusing effect that increased the surface dose by approximately 10%. Conclusions: Results of this work allow for consideration of different bolus thicknesses, materials, and usage schedules based on desired skin dose and choice of either tangents or an arc beam techniques. [ABSTRACT FROM AUTHOR]

Hearing aid impression material composed of vinylpolysiloxane is an ideal bolus material which may be used to aid in delivery of adjuvant radiation to complex surgical defects of the head and neck. It is affordable, easily accessed, and efficient. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to evaluate the efficacy of a synthesized bolus in the reduction of damage to body tissues and the protection of the organ at risk (OAR) in radiotherapy application. Several properties of the synthesized bolus, including density, transmission factor, and effective mass attenuation coefficient, were investigated. Material and Methods: The materials used comprising of propylene glycol (PG), silicone rubber (SR), and aluminum (Al). The dimension of the synthesized bolus was measured using an acrylic case with a size of 11×11 cm² and thickness sizes of 0.5, 1, and 1.5 cm. Furthermore, the boluses were irradiated by linear accelerator with the photon beam energies of 6 and 10 MV, using linier accelerator (LINAC) Varian 2300ix. Results: In this research, the density of synthesized bolus was evaluated by mass per volume equation. The results showed that the density of bolus was similar to the density of tissue/water, fat, and air. Furthermore the bolus with the composition of PG 24%, SR 8%, and Al 1.5% of all energies, transmission factors of 0.978 and 0.984, thickness of 1.5 cm, and effective mass attenuation coefficients of 0.0144 and 0.0107 cm²/g had the closest properties to the body tissues in terms of dosimetry characterization. Conclusion: The results revealed that the synthesized bolus could increase the percentage surface dose, reduce skin-sparing effect, and protect OAR. The findings indicated that the synthesized bolus had a potential application in clinical therapy. [ABSTRACT FROM AUTHOR]

Introduction: To estimate the clinical impact of bolus in intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) for stage I–II nasal natural killer/T-cell lymphoma (NNKTCL), including target quality, organs at risk (OARs) sparing, and tumor control probability (TCP). Methods: Two different treatment plans were designed in IMRT and VMAT for 10 stage I–II NNKTCL patients. The clinical plans added bolus perfectly contacting the nose skin, similar to common clinical planning design practices. The edited bolus plans resulted from dose recalculation with the edited bolus, which simulated the actual shape of a commercial flat bolus during treatment. All the plans were with no beam passing through the couch avoiding beam attenuation caused by the couch. Differences between both types of plans in target quality, OARs sparing, and TCP were evaluated. Results: Compared with clinical plans, the D98%, D2%, Dmean, and TCP of edited bolus plans with IMRT slightly decreased (p = 0.002, 0.015, 0.000, and 0.000), the homogeneity index increased 8.33% (p = 0.024), and the doses to a small number of OARs slightly changed. Similar results were obtained for VMAT. Conclusion: The bolus deformation in practical clinical treatment resulted clinically in tiny changes with respect to the target coverage, OARs sparing, and TCP in both IMRT and VMAT for stage I–II NNKTCL. This implied that the clinical impact of the boluscan be negligible when utilizing it to increase the dose to irregularly shaped tumors in the nasal area. [ABSTRACT FROM AUTHOR]

Introduction: Three‐dimensional printing technology has the potential to streamline custom bolus production in radiotherapy. This study evaluates the volumetric, dosimetric and cost differences between traditional wax and 3D printed versions of nose bolus. Method: Nose plaster impressions from 24 volunteers were CT scanned and planned. Planned virtual bolus was manufactured in wax and created in 3D print (100% and 18% shell infill density) for comparison. To compare volume variations and dosimetry, each constructed bolus was CT scanned and a plan replicating the reference plan fields generated. Bolus manufacture time and material costs were analysed. Results: Mean volume differences between the virtual bolus (VB) and wax, and the VB and 18% and 100% 3D shells were −3.05 ± 11.06 cm3, −1.03 ± 8.09 cm3 and 1.31 ± 2.63 cm3, respectively. While there was no significant difference for the point and mean doses between the 100% 3D shell filled with water and the VB plans (P> 0.05), the intraclass coefficients for these dose metrics for the 100% 3D shell filled with wax compared to VB doses (0.69–0.96) were higher than those for the 18% and 100% 3D shell filled with water and the wax (0.48–0.88). Average costs for staff time and materials were higher for the wax ($138.54 and $20.49, respectively) compared with the 3D shell prints ($10.58 and $13.87, respectively). Conclusion: Three‐dimensional printed bolus replicated the VB geometry with less cost for manufacture than wax bolus. When shells are printed with 100% infill density, 3D bolus dosimetrically replicates the reference plan. [ABSTRACT FROM AUTHOR]

Purpose: Radiochromic film remains a useful and versatile clinical dosimetry tool. Current film options are single use. Here, we introduce a novel prototype two‐dimensional (2D) radiochromic sheet, which optically clears naturally at room temperature after irradiation and can be reused. We evaluate the sheets for potential as a 2D dosimeter and as a radiochromic bolus with capability for dose measurement. Methods: A novel derivative of reusable Presage® was manufactured into thin sheets of 5 mm thickness. The sheets contained 2% cumin‐leucomalachitegreen‐diethylamine (LMG‐DEA) and plasticizer (up to 25% by weight). Irradiation experiments were performed to characterize the response to megavoltage radiation, including dose sensitivity, temporal decay rate, consistency of repeat irradiations, intra and inter‐sheet reproducibility, multi‐modality response (electrons and photons), and temperature sensitivity (22°C to 36°C). The local change in optical‐density (ΔOD), before and after radiation, was obtained with a flat‐bed film scanner and extracting the red channel. Repeat scanning enabled investigation of the temporal decay of ΔOD. Additional studies investigated clinical utility of the sheets through application to IMRT treatment plans (prostate and a TG119 commissioning plan), and a chest wall electron boost treatment. In the latter test, the sheet performed as a radiochromic bolus. Results: The radiation induced OD change in the sheets was found to be proportional to dose and to exponentially decay to baseline in ~24 h (R2 = 0.9986). The sheet could be reused and had similar sensitivity (within 1% after the first irradiation) for at least eight irradiations. Importantly, no memory of previous irradiations was observed within measurement uncertainty. The consistency of dose response from photons (6 and 15 MV) and electrons (6–20 MeV) was found to be within calibration uncertainty (~1%). The dose sensitivity of the sheets had a temperature dependence of 0.0012 ΔOD/°C. For the short (1 min) single field IMRT QA verification, good agreement was observed between the Presage sheet and EBT film (gamma pass rate 97% at 3% 3 mm dose‐difference and distance‐to‐agreement tolerance, with a 10% threshold). For the longer (~13 min) TG‐119 9‐field IMRT verification the gamma agreement was lower at 93% pass rate at 5% 3 mm, 10% threshold, when compared with Eclipse. The lower rate is attributed to uncertainty arising from signal decay during irradiation and indicates a current limitation. For the electron cutout treatment, both Presage and EBT agreed well (within 2% RMS difference) but differed from the Eclipse treatment plan (~7% RMS difference) indicating some limitations to the Eclipse modeling in this case. The worst case estimates of uncertainty introduced by the signal decay for deliveries of 2, 5, and 10 min are 0.6%, 1.4%, and 2.8% respectively. Conclusions: Reusable Presage sheets show promise for 2D dose measurement and as a radiochromic bolus for in vivo dose measurement. The current prototype is suitable for deliveries of length up to 5 min, where the uncertainty introduced by signal decay is anticipated to be ~1% (worst case 1.4%), or for longer deliveries where there is no temporal modulation (e.g. physical compensators, or open beams). Additionally, spatial resolution is limited by sheet thickness and scanner resolution, resulting in a practical resolution of 0.8 mm. [ABSTRACT FROM AUTHOR]

A dosimetric analysis of a commercially available thermoplastic sheet bolus, Klarity EZ BolusTM, was completed. Attenuation characteristics were evaluated using different configurations of a rectilinear water-mimicking plastic phantom irradiated by a high-energy linear accelerator using three photon energies, five electron energies. These results were compared with data obtained during the linear accelerator commissioning process to determine depths of water that attenuated beams similarly. CT scans of the flat, unmolded sheet bolus, as well as of the bolus molded to a cylindrical phantom, were analyzed. The product was found to form a durable and rigid, contour-specific bolus with a water-equivalent thickness of approximately 6 mm for a single sheet, and 11 mm for two sheets in tandem. [ABSTRACT FROM AUTHOR]

Purpose: This case series represents an initial experience with implementing 3‐dimensional (3D) surface scanning, digital design, and 3D printing for bolus fabrication for patients with complex surface anatomy where traditional approaches are challenging. Methods and Materials: For 10 patients requiring bolus in regions with complex contours, bolus was designed digitally from 3D surface scanning data or computed tomography (CT) images using either a treatment planning system or mesh editing software. Boluses were printed using a fused deposition modeling printer with polylactic acid. Quality assurance tests were performed for each printed bolus to verify density and shape. Results: For 9 of 10 patients, digitally designed boluses were used for treatment with no issues. In 1 case, the bolus was not used because dosimetric requirements were met without the bolus. QA tests revealed that the bulk density was within 3% of the reference value for 9 of 12 prints, and with more judicious selection of print settings this could be increased. For these 9 prints, density uniformity was as good as or better than our traditional sheet bolus material. The average shape error of the pieces was less than 0.5 mm, and no issues with fit or comfort were encountered during use. Conclusions: This study demonstrates that new technologies such as 3D surface scanning, digital design and 3D printing can be safely and effectively used to modernize bolus fabrication. [ABSTRACT FROM AUTHOR]

Background: Postmastectomy radiation (PMRT) to the chest wall using electron beam treatment with uniform bolus was practiced at our institution. The planning target volume (PTV) included the chest wall and the internal mammary nodes (IMN) along with supraclavicular nodal regions. The varying thickness of the postmastectomy chest wall and the varying position of the IMN resulted in dose inhomogeneity in the PTV. In addition, there was the risk of increased lung and cardiac doses. In this prospective study, we report the making of a custom-made bolus using dental wax called "step bolus."Materials and Methods: From March 2010 to January 2011, 167 patients received PMRT. As conformal photon plans were not acceptable in 48 patients, they were treated with single energy electrons and custom-made bolus.Results: Addition of the step bolus improved dose distribution to the PTV reduced the mean lung dose %, the mean heart dose % and lung dose (D10, D20, D30, D50, and D70). Forty-seven patients had Grade 2, and one patient had Grade 3 skin toxicity. Acute symptomatic radiation pneumonitis was observed in one patient. At 5 years, 29 patients were alive with a median follow-up of 32 months and no local recurrences were observed. One patient died of myocardial infarction unrelated to treatment, one patient did not come for follow-up, 22 patients had systemic metastases, and 24 patients were disease free.Conclusion: A custom-made step bolus using dental wax can be used for tissue compensation in electron beam therapy with resulting good local disease control and acceptable toxicity. [ABSTRACT FROM AUTHOR]

Abstract Radiation therapy is an effective treatment for primary orbital lymphomas. Lens shielding with electrons can reduce the risk of high-grade cataracts in patients undergoing treatment for superficial tumors. This work evaluates the dosimetric effects of a suspended eye shield, placement of bolus, and varying electron energies. Film (GafChromic EBT3) dosimetry and relative output factors were measured for 6, 8, and 10 MeV electron energies. A customized 5-cm diameter circle electron orbital cutout was constructed for a 6 × 6-cm applicator with a suspended lens shield (8-mm diameter Cerrobend cylinder, 2.2-cm length). Point doses were measured using a scanning electron diode in a solid water phantom at depths representative of the anterior and posterior lens. Depth dose profiles were compared for 0-mm, 3-mm, and 5-mm bolus thicknesses. At 5 mm (the approximate distance of the anterior lens from the surface of the cornea), the percent depth dose under the suspended lens shield was reduced to 15%, 15%, and 14% for electron energies 6, 8, and 10 MeV, respectively. Applying bolus reduced the benefit of lens shielding by increasing the estimated doses under the block to 27% for 3-mm and 44% for 5-mm bolus for a 6 MeV incident electron beam. This effect is minimized with 8 MeV electron beams where the corresponding values were 15.5% and 18% for 3-mm and 5-mm bolus. Introduction of a 7-mm hole in 5-mm bolus to stabilize eye motion during treatment altered lens doses by about 1%. Careful selection of electron energy and consideration of bolus effects are needed to account for electron scatter under a lens shield. [ABSTRACT FROM AUTHOR]

In‐phantom and in‐vivo three dimensional conformal radiation therapy (3DCRT) and volumetric modulated arc therapy (VMAT) skin doses, measured with and without bolus in a female anthropomorphic phantom RANDO and in patients, were compared against treatment planning system calculated values. A thorough characterization of the metal oxide semiconductor field effect transistor measurement system was performed prior to the measurements in phantoms and patients. Patients with clinical indication for postoperative external radiotherapy were selected. Skin dose showed higher values with 3DCRT technique compared with VMAT. The increase in skin dose due to the use of bolus was quantified. It was observed that, in the case of VMAT, the bolus effect on the skin dose was considerable when compared with 3DCRT. From the point of view of treatment time, bolus cost, and positioning reproducibility, the use of bolus in these situations can be optimized. [ABSTRACT FROM AUTHOR]

This work presents the optimized parameters of 3D printing for print bolus using BolusCM material. Printing parameters were selected of the homogeneity and absence of air gaps. The dosimetric features of printed bolus were measured with a plane-parallel ionization chamber and EBT3 radiochromic film. Measured features were compared with those estimated with Monte Carlo methods. BolusCM shows good characteristics to be used as bolus material in radiotherapy with electrons, where the printing process allows personalizing the bolus in function of patient characteristics. The material low-cost, the 3D printing and the dosimetric features are few of the advantages of using BolusCM material in radiotherapy with electrons in skin cancer treatment. • BolusCM is presented as a material for use in 3D-printing of bolus in electron beam therapy. • A devide for manufacturing 3D-printed BolusCM using free software is presented. • Dosimetric constancy of BolusCM properties is verified for 3D-printed boluses. • 3D-printed boluses with BolusCM does not show cracks or air gaps. • 3D printed bolus using PLA filament is compared with BolusCM 3D printed. • BolusCM material 3D-printed boluses can be implemented as a low-cost and high-reliability bolus in radiotherapy. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to measure entrance skin dose (ESD) on the breast of patients who had undergone radiotherapy following surgery, in the presence and absence of bolus.Materials and Methods: In this study, the ESD on the breast of 22 female patients was measured using thermoluminescent dosimeter-100 chips. For each patient, the ESD was measured 3 times (once without bolus and twice using bolus). The bolus types used in this study include super flab and wax.Results: The average ESDs on the breast of patients (from both medial and lateral tangential fields) in the presence of the super flab bolus and absence of bolus were 225.8 and 148.17 cGy, respectively, that when using the bolus, around 52% increasing in ESD was observed. The results showed a significant relationship between the ESD on the breast of patients and bolus types (P = 0.002); in addition, correlation coefficient between the two boluses (super flab and wax) was 0.615 (r = 0.615).Conclusion: When using the bolus in postmastectomy irradiation, it is noted that in dose delivery to the chest wall, surgical scar or skin of the treated region should be considered. The use of the bolus as a substance that increases of the skin dose can sometimes cause an excessive increase in skin dose that may cause severe skin reactions and underdosing of underlying tissues. Furthermore, using wax bolus in regions that do not require a lot of shaping of bolus is affordable. [ABSTRACT FROM AUTHOR]

Introduction: The present study aimed to generate intensity-modulated beams with Aluminium compensating filters for a conventional telecobalt machine based on the outputs of a treatment planning system (TPS) performing forward planning and cannot simulate directly the compensating filter. Materials and Methods: In order to achieve the beam intensity modulation during treatment planning with the TPS, we used a bolus placed on the surface of a tissue-equivalent phantom. The treatment plans replicated on the telecobalt machine with the bolus were represented with compensating filters placed at a certain distance from the phantom surface. An equation was proposed for the conversion of the bolus thickness to the compensating filter thickness such that any point within the phantom would receive the planned dose. Correction factors were introduced into the proposed equation to account for the influences of field size, treatment depth, and applied bolus thickness. The proposed equation was obtained based on the analyses of empirical data measured in a full scatter water phantom with and without the compensating filter. Results: According to the results, the dosimetric verification of the proposed approach outputs in a solid water phantom with calibrated Gafchromic EBT2 films were comparable to that of the TPS with deviation of ±4.73% (mean: 2.98±1.05%). Conclusion: As the findings of the present study indicated, the discrepancy between the measured doses and TPS-estimated doses was within the tolerance of ±5%, which is recommended for dose delivery in external beam radiotherapy. Therefore, the proposed approach is recommended for clinical application. [ABSTRACT FROM AUTHOR]

Abstract: Special attention is required in planning and administering radiation therapy to patients with cardiac implantable electronic devices (CIEDs), such as pacemaker and defibrillator. The range of dose to CIEDs that can induce malfunction is large among CIEDs. Clinically significant defects have been reported at dose as low as 0.15 Gy. Therefore, accurate estimation of dose to CIED and dose reduction are both important even if the dose is expected to be less than the often‐used 2‐Gy limit. We investigated the use of bolus in in vivo dosimetry for CIEDs. Solid water phantom measurements of out‐of‐field dose for a 6‐MV beam were performed using parallel plate chamber with and without 1‐ to 2‐cm bolus covering the chamber. In vivo dosimetry at skin surface above the CIED was performed with and without bolus covering the CIED for three patients with the CIED <5 cm from the field edge. Chamber measured dose at depth ~0.5–1.5 cm below the skin surface, where the CIED is normally located, was reduced by ~7–48% with bolus. The dose reduction became smaller at deeper depths and with smaller field size. In vivo dosimetry at skin surface also indicated ~20%–60% lower dose when using bolus for the three patients. The dose measured with bolus more accurately reflects the dose to CIED and is less affected by contaminant electrons and linac head scatter. In general, the treatment planning system (TPS) calculation underestimated the dose to CIED, but it predicts the CIED dose more accurately when bolus is used. We recommend the use of 1‐ to 2‐cm bolus to cover the CIED during in vivo CIED dose measurements for more accurate CIED dose estimation. If the CIED is placed <2 cm in depth and its dose is mainly from anterior beams, we recommend using the bolus during the entire course of radiation delivery to reduce the dose to CIED. [ABSTRACT FROM AUTHOR]

An essential issue is an accurate evaluation of surface dose distribution for such sensitive treatments. This work aimed to feasibility of the dual application of the Ferrous Polyvinyl Alcohol Glutaraldehyde Methylthymol Blue (PVA-GTA-MTB) gel as a bolus compensator and surface dosimeter in breast radiotherapy. The differences between the surface dose measured using PVA-GTA-MTB gel and film dosimetry in the medial and lateral parts of the breast were 3.74% and 4.18%, respectively. A qualitative comparison of the isodose curves showed that the PVA-GTA-MTB bolus creates a uniform dose distribution similar to the superflab bolus in the target volume. • Preparation of PVA-GTA-MTB Fricke hydrogel. • Dose calibration curves for the radiochromic hydrogel and film dosimetry. • Role of PVA-GTA-MTB Fricke hydrogel as radiotherapy bolus. [ABSTRACT FROM AUTHOR]

In this research, we aim to investigate the influence of different materials, as a bolus, on the low-energy electron beam dose distributions and to develop equations for predicting surface dose based on bolus thickness, as well as the therapeutic interval based on surface dose. All the Monte Carlo (MC) calculations and measurements were conducted on a Siemens PRIMUS linac. Based on EGSnrc MC code, BEAMnrc system was used to model a Siemens linac and generate phase-space files for three electron beams (6, 8, and 10 MeV). The particles were transported from the phase-space files to the bolus materials and the simulated water phantom using DOSXYZnrc. Various materials with different thicknesses were examined as a bolus, and appropriate equations were determined for each material and electron beam. The comparison of percent depth dose (PDD) curves and beam profiles, using MC, with the measured data demonstrated that the calculated values properly matched with the measurements. The results indicated that the use of bolus materials with the density of higher than soft tissue can increase both surface dose and therapeutic interval simultaneously. This finding arises from the fact that the required bolus thickness for achieving the therapeutic surface dose decreases in the case of high-density materials. Two series of prediction equations were proposed for predicting the surface dose based on bolus thickness and the therapeutic interval based on surface dose. These equations are able to calculate properly the bolus thickness required for producing a therapeutic surface dose (above 90%) for any therapeutic interval. [ABSTRACT FROM AUTHOR]

Background and purpose Creating an individualized tissue equivalent material build-up (i.e. bolus) for electron beam radiation therapy is complex and highly labour-intensive. We implemented a new clinical workflow in which 3D printing technology is used to create the bolus. Material and methods A patient-specific bolus is designed in the treatment planning system (TPS) and a shell around it is created in the TPS. The shell is printed and subsequently filled with silicone rubber to make the bolus. Before clinical implementation we performed a planning study with 11 patients to evaluate the difference in tumour coverage between the designed 3D-print bolus and the clinically delivered plan with manually created bolus. For the first 15 clinical patients a second CT scan with the 3D-print bolus was performed to verify the geometrical accuracy. Results The planning study showed that the V85% of the CTV was on average 97% (3D-print) vs 88% (conventional). Geometric comparison of the 3D-print bolus to the originally contoured bolus showed a high similarity (DSC = 0.89). The dose distributions on the second CT scan with the 3D print bolus in position showed only small differences in comparison to the original planning CT scan. Conclusions The implemented workflow is feasible, patient friendly, safe, and results in high quality dose distributions. This new technique increases time efficiency. [ABSTRACT FROM AUTHOR]

American Association of Physicists in Medicine (AAPM) Task Group 176 evaluated the dosimetric effects caused by couch tops and immobilization devices. The report analyzed the extensive physics-based literature on couch tops, stereotactic body radiation therapy (SBRT) frames, and body immobilization bags, while noting the scarcity of clinical reports of skin toxicity because of external devices. Here, we present a clinical case report of grade 1 abdominal skin toxicity owing to an abdominal compression device. We discuss the dosimetric implications of the utilized treatment plan as well as post hoc alternative plans and quantify differences in attenuation and skin dose/build-up between the device, a lower-density alternative device, and an open field. The description of the case includes a 66-year-old male with HER2 amplified poorly differentiated distal esophageal adenocarcinoma treated with neoadjuvant chemo-radiation and the use of an abdominal compression device. Radiation was delivered using volumetric modulated arc therapy (VMAT) with 2 arcs using abdominal compression and image guidance. The total dose was 50.4 Gy delivered over 40 elapsed days. With 2 fractions remaining, the patient developed dermatitis in the area of the compression device. The original treatment plan did not include a contour of the device. Alternative post hoc treatment plans were generated, one to contour the device and a second with anterior avoidance. In conclusion, replanning with the device contoured revealed the bolus effect. The skin dose increased from 27 to 36 Gy. planned target volume (PTV) coverage at 45 Gy was reduced to 76.5% from 95.8%. The second VMAT treatment plan with an anterior avoidance sector and more oblique beam angles maintained PTV coverage and spared the anterior wall, however at the expense of substantially increased dose to lung. This case report provides an important reminder of the bolus effect from external devices such as abdominal compression. Special consideration must be given to contour and/or avoiding beam entrance to the device, and to the use of such devices in patients who may have heightened radiosensitivity, such as those who are human immunodeficiency virus (HIV)–positive. [ABSTRACT FROM AUTHOR]

The brass mesh bolus alloy has been shown to be a promising substitute for tissue-equivalent bolus to increase the surface dose during breast cancer radiotherapy treatment. This study is aimed to evaluate the brass alloy density in order to better understand the brass qualities as a bolus in radiotherapy. The mass density of brass alloy determined in this work are using solid approaches, i) traditional density method, ii) Computed Tomography (CT) number using electron density phantom and CT scan and iii) mean pixel value via ImageJ software. According to ANOVA F (2,6) 2.982, p0.126, there was no statistically significant difference between the groups. As a result, all methods for calculating the density of brass alloy are valid. The X2 test of CT number of brass plug to breast substitute in electron density phantom indicates no association. Density analysis using computed tomography and an electron density phantom, as well as the traditional density method and Image J analysis, were all shown to be acceptable methods for estimating the density of the brass alloy. Considering this, brass alloy can be considered as a potential substitute for tissue-equivalent bolus with further extensive of research in conjunction to CT number. [Display omitted] • The value of brass alloy density given by CT and Image J methods are ±0.24% and 0.81% with theoretical density value methodology. • Density analysis by CT and electron density phantom, conventional density method and Image J analysis are statistically significance proven. • The CT number analysis cannot prove the density of brass alloy in close proximity to breast tissue density by Chi Square test. [ABSTRACT FROM AUTHOR]

Abstract: The dosimetric effect of errors in patient position is studied on-phantom as a function of simulated bolus thickness to assess the need for bolus utilization in scalp radiotherapy with tomotherapy. A treatment plan is generated on a cylindrical phantom, mimicking a radiotherapy technique for the scalp utilizing primarily tangential beamlets. A planning target volume with embedded scalplike clinical target volumes (CTVs) is planned to a uniform dose of 200cGy. Translational errors in phantom position are introduced in 1-mm increments and dose is recomputed from the original sinogram. For each error the maximum dose, minimum dose, clinical target dose homogeneity index (HI), and dose-volume histogram (DVH) are presented for simulated bolus thicknesses from 0 to 10mm. Baseline HI values for all bolus thicknesses were in the 5.5 to 7.0 range, increasing to a maximum of 18.0 to 30.5 for the largest positioning errors when 0 to 2mm of bolus is used. Utilizing 5mm of bolus resulted in a maximum HI value of 9.5 for the largest positioning errors. Using 0 to 2mm of bolus resulted in minimum and maximum dose values of 85% to 94% and 118% to 125% of the prescription dose, respectively. When using 5mm of bolus these values were 98.5% and 109.5%. DVHs showed minimal changes in CTV dose coverage when using 5mm of bolus, even for the largest positioning errors. CTV dose homogeneity becomes increasingly sensitive to errors in patient position as bolus thickness decreases when treating the scalp with primarily tangential beamlets. Performing a radial expansion of the scalp CTV into 5mm of bolus material minimizes dosimetric sensitivity to errors in patient position as large as 5mm and is therefore recommended. [Copyright &y& Elsevier]

Abstract: Frequently, in radiation therapy one must treat superficial lesions on cancer patients; these are at or adjacent to the skin. Megavoltage photon radiotherapy penetrates through the skin to irradiate deep-seated tumors, with skin-sparing property. Hence, to treat superficial lesions, one must use a layer of scattering material to feign as the skin surface. Although megavoltage electron beams are used for superficial treatments, one occasionally needs to enhance the dose near the surface. Such is the function of a “bolus,” a natural or synthetically developed material that acts as a layer of tissue to provide a more effective treatment to the superficial lesions. Other uses of boluses are to correct for varying surface contours and to add scattering material around the patient's surface. Materials used as bolus vary from simple water to metal and include various mixtures and compounds. Even with the modernization of the technology for external-beam therapy and the emergence of various commercial boluses, the preparation and utilization of a bolus in clinical radiotherapy remains an art. Considering the varying experiences and practices, this paper briefly summarizes available boluses that have been proposed and are employed in clinical radiotherapy. Although this review is not exhaustive, it provides some initial guidance and answers questions that may arise in clinical practice. [Copyright &y& Elsevier]

[Display omitted] • Our systematic review of bolus use during PMRT made two important findings: • Bolus use leads to more acute toxicity. • Bolus use does not seem to improve local control, unless patient is high risk. • Bolus may be only indicated for patients with a high risk of local recurrence. Post mastectomy radiation therapy (PMRT) reduces locoregional recurrence (LRR) and breast cancer mortality for selected patients. Bolus overcomes the skin-sparing effect of external-beam radiotherapy, ensuring adequate dose to superficial regions at risk of local recurrence (LR). This systematic review summarizes the current evidence regarding the impact of bolus on LR and acute toxicity in the setting of PMRT. 27 studies were included. The use of bolus led to higher rates of acute grade 3 radiation dermatitis (pooled rates of 9.6% with bolus vs. 1.2% without). Pooled crude LR rates from thirteen studies (n = 3756) were similar with (3.5%) and without (3.6%) bolus. Bolus may be indicated in cases with a high risk of LR in the skin, but seems not to be necessary for all patients. Further work is needed to define the role of bolus in PMRT. [ABSTRACT FROM AUTHOR]

Changes that happen with aging have an effect on food texture perception and oral processing behaviour. Mastication and saliva incorporation are two major aspects of oral processing which can be used to evaluate the texture perception of food. This study aimed to investigate inter-oral responses of healthy individuals during chewing in relation to cooked meat texture. Mastication variables were recorded during the chewing process and boluses were collected and analysed for saliva impregnation and particle size distribution. Increasing hardness of meat did not change the number or duration of chewing cycles, but particle breakdown was significantly increased (P < 0.05) with the hardness of meat. As a result more saliva was required to agglomerate harder particles in order to make a safe swallow cohesive bolus. Two different groups were identified in relation to texture responses where one group was able to swallow samples with less saliva incorporated into it and cohesiveness was due to less fragmented muscle fibres and meat juice whereas other group had relatively higher saliva incorporation to obtain cohesiveness of particles. • Physiological properties and particle size of beef boluses were analysed in relation to the initial cooked beef texture. • Number of chews and chewing duration were not affected by the texture of beef. • Saliva incorporation and particle breakdown were influenced by the cooked meat texture. • Significant level of inter panellist variability was observed in all the studied parameters. [ABSTRACT FROM AUTHOR]

This study assessed the usefulness of the miniature Kramer shear cell to determine relevant instrumental parameters of solid foods and bolus counterparts, examining their relationships with oral processing behaviors to obtain greater knowledge about the texture perception process. Six solid foods with different textural properties were tested. Bolus mechanical properties were also determined by means of cone penetration tests and rheological measurements, and their particle size distributions by sieving. Oral processing behavior (chewing time, number of chews, chewing rate, eating rate) and food saliva uptake (SU) of a young volunteer and a panel of 39 untrained participants were analyzed. The Kramer mechanical properties were very suitable for detecting different levels of food and bolus textural hardness and fracturability and the associated degrees of fragmentation achieved during mastication. Chewing time and number of chews were highly correlated with Kramer food and bolus mechanical properties for the single subject and for the panel's oral processing behaviors. For the single subject, SU and eating rate also showed strong correlations with food and bolus mechanical properties, unlike chewing rate and food moisture content (FMC). In contrast, eating rate, FMC, and SU did not vary with the oral activities of the panel. [ABSTRACT FROM AUTHOR]

Abstract: For certain clinical situations such as breast treatments, a bolus is used and must be accounted for in monitor unit calculations. Because of the oblique incidence involved, the thickness of bolus traversed by the radiation beam, as opposed to its nominal thickness, must be used. Using principles of geometry, a simple method is derived to calculate the thickness of bolus for these calculations. [Copyright &y& Elsevier]