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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 To
better understand how to manage this side effect, a comparison study of different TEB thickness
and frequency was evaluated. 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.

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 1 in 8
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
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,
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patients undergo a mastectomy prior to radiation treatment. 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. Involved lymph nodes may include the supraclavicular,
axillary lymph node levels 1-3, and internal mammary nodes.2 The curvature of the chestwall
and patient size can create a challenge for radiotherapy treatment planning. The frequently used
photon beams reach peak effectiveness at a particular depth, which can result in an under-dosage
of the skin surface, and 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.6,7
Bolus emulates human soft tissue and has a density of 1.0 g/ml.8,9 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.5,10 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 assist with treating 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 curvature of the chestwall, body size, and the thickness and frequency of
bolus used.10-13 The challenge for physicians is deciding the proper amount of bolus to
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 3 mm
bolus consisted of Superflab or Elasto-Gel, while the 5 mm bolus consisted of Elasto-Gel. 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.
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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 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.
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), planning target
volume (PTV), and the supraclavicular nodal PTV volume. The CTV was designed to
encompass the surgical bed, while the supraclavicular PTV volume denoted the location of the
supraclavicular lymph nodes. 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. The 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 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. The participating facilities in this research study used 2 different treatment
planning systems (TPSs). Facility 1 used Eclipse, while facility 2 used Pinnacle.
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
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the patient’s chestwall. 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, to a total dose of 5,000 cGy. For both facilities, the physicians
required 95% of the PTV and nodal volumes to receive 100% of the prescription dose. The only
aspect of the prescription that varied between patients was the thickness and variation of the
bolus used.
Every patient involved in this study was treated using bolus. Facility 1 data used 3 mm
bolus daily, while facility 2 used 5 mm bolus every other day. Each facility used both Superflab
and Elastogel bolus for their treatments.
Results
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
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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,
Elastogel and Superflab were considered equivalent bolus material, and no difference in density
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. For facility 1 during the first week of treatment, 91% of patients reported no skin reaction.
The second week showed 30% of patients reporting no skin reaction with 70% scoring a 1 on the
radiation dermatitis index. During the third week of treatment, 96% of patients scored a 1 with
only 4% experiencing no skin reaction. On the fourth week of treatment, 83% scored a 1 and
17% received a 2 on the radiation dermatitis index.
In contrast, during the first week, 85% of patients at facility 2 reported no skin reaction.
On the second week of treatment, 55% indicated no skin reaction with 45% of patients scoring a
1 on the radiation dermatitis index. For week three, 20% of patients had no skin reaction and
70% scored a 1. During week four, 70% scored a 1 and 25% of patients scored a 2 on the index.
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 no significant difference
between facilities 1 and 2, by earning a p-value of 0.368.16 (Figures 1 and 2)
Discussion
No observable disproportionate results were found when comparing the 2 facilities’
radiation dermatitis data. Rather, a “seesaw effect” was observed. One facility’s radiation
dermatitis score would be marginally higher one week only to be slightly overtaken by the other
facility the next week. When the data was evaluated on a large scale, compared with the existing
literature on TEB usage and radiation dermatitis, the results displaying no significant difference
between bolus techniques were clearly supported by numerous journal articles.2-4,6-11 Each of
these supporting studies focused on a combination of the use of bolus to determine what caused
an increase in radiation dermatitis.
For TEB, the common outcome was that an increase in bolus thickness resulted in a rise
in surface dose. This led to an upturn in radiation dermatitis. In the researchers’ literature
review, there was only 1 study that indicated otherwise. This was due to a bolus thickness that,
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when combined with the angle of incidence, had a treatment beam dmax depth that did not reach
the skin surface.3 If the highest dose does not deposit at the skin surface, then the result of less
skin dose from an increase in bolus thickness is to be expected.1,3,5,8
Another important result is the frequency of bolus usage during a treatment regimen. In
an extensive study by Andic, et al, it was determined that an increase in bolus usage frequency
had a direct correlation with skin toxicity.4 Therefore, not only had the use of bolus demonstrated
an increase in skin toxicity, but the number of times the bolus was used also increased skin
toxicity. It is the blending of these 2 causalities that have produced a null result when the
researchers analyzed the data from facilities 1 and 2 in this study.
Conclusion
The anticipated effects from the 2 mm variance in bolus thickness between facilities 1
and 2 were negated by the difference in the number of uses per fraction of TEB by each facility.
The fact that no statistical significance in radiation dermatitis was found between the 2 facilities
was the greatest strength the researchers found in this study. The result is an affirmation that
differing bolus methodologies can produce similar results. Therefore, future studies designed to
find a difference in radiation dermatitis would benefit from having either boluses of different
compositions or different fractionation patterns. Another suggestion would be to track radiation
dermatitis 1-2 weeks after treatment has ended to observe the radiotherapeutic effects still
occurring post-treatment.1,5,9
Limitations of this study include its retrospective nature and small sample size from only
2 facilities. This did not allow the researchers to examine multiple TEBs or non-tissue equivalent
boluses that have been used at other treatment centers.2,3,6-8 Additionally, the use of one type of
TEB for both facilities would have held the results to a higher standard than the use of TEB from
2 different manufacturers.
In conclusion, there is little difference in skin toxicity between using 3 mm bolus every
day and 5 mm bolus every other day for the sample size observed. This study achieved its goal
by providing results for the analysis of 2 different treatment methods and their effects on skin
toxicity. 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 no risk of further skin damage by selecting 1 TEB method over another.
The primary goal of radiation therapy is to provide quality treatments to patients with minimal
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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.

We would like to express our thanks to Dr. David Reineke, Thomas Theisen, and Carsten
Hiltgen of the UWL Statistical Consulting Center for their contribution to the statistical analysis
and interpretation of statistical results.
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References
1. Washington CM, Leaver DT. Principles and Practice of Radiation Therapy. 3rd ed.
Philadelphia: Elsevier Health Sciences; 2009.
2. Healy E, Anderson S, Cui J, et al. Skin dose effects of postmastectomy chest wall radiation
therapy using brass mesh as an alternative to tissue equivalent bolus. Pract Radiat Oncol.
2013; In Press. https://dx.doi.org/10.1016/j.prro.2012.05.009
3. Hsu SH, Roberson PL, Chen Y, et al. Assessment of skin dose for breast chest wall
radiotherapy as a function of bolus material. Phys Med Biol. 2008;53:2593-2606.
https://dx.doi.org/10.1088/0031-9155/53/10/010
4. Andic F, Ors Y, Davutoglu R, et al. Evaluation of skin dose associated with different
frequencies of bolus applications in post-mastectomy three-dimensional conformal
radiotherapy. J Exp Clin Cancer Res. 2009;28-41.
https://dx.doi.org/10.1186/1756-9966-28-41
5. Khan FM. The Physics of Radiation Therapy. 3rd ed. Lippincott Williams and Wilkins,
Philadelphia; 2003.
6. Radiation Products Design, Inc. Radiation Products Design, Inc. RPD Inc
website. https://www.rpdinc.com/super-stuff-bolus-10-pound-bucket-1723.html. Accessed
September 16, 2018.
7. Radiation Products Design, Inc. Radiation Products Design, Inc. RPD Inc website.
https://www.rpdinc.com/elasto-gel-05cm-thick-x-30cm-square-1716.html. Accessed
September 16, 2018.
8. Visscher S, Barnett E. Comparison of bolus materials to highly absorbent
polypropylene and rayon cloth. J Med Imaging Radiat Sc. 2017;48(1):55-60.
https://dx.doi.org/10.1016/j.jmir.2016.08.003
9. Humphries S, Boyd K, Cornish P, & Newman F. Comparison of super stuff and paraffin
wax bolus in radiation therapy of irregular surfaces. Med Dosim. 1996;21(3):155-157.
https://dx.doi.org/10.1016/0958-3947(96)00076-3
10. Letourneau M, Hogue J, Desbiens C, Theberge V. Outcomes in postmastectomy patients
treated by adjuvant radiation therapy without application of bolus. Int J Radiat Oncol Biol
Phys. 2012;84(3)S247. https://dx.doi.org/10.1016/j.ijrobp.2012.07.641
11. Pignol JP, Vu TT, Mitera G, et al. Prospective evaluation of severe skin toxicity and
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pain during postmastectomy radiation therapy. Int J Radiat Oncol.Biol Phys.

2015;91(1):157-164. https://dx.doi.org/10.1016/j.ijrobp.2014.09.022
12. Asher D, Johnson P, Dogan N, et al. Acute skin toxicity is comparable between brass
bolus and 0.5 mm tissue equivalent bolus among women receiving postmastectomy
irradiation using mixed energy photons. Int J Radiat Oncol Biol Phys. 2017;99(2):E3-E3.
https://dx.doi.org/10.1016/j.ijrobp.2017.06.597
13. Parekh A, Dholakia A, Zabransky D, et al. Predictors of radiation-induced acute skin
toxicity in breast cancer at a single institution: Role of fractionation and treatment volume.
Adv Radiat Oncol. 2018;3(1):8-15. https://dx.doi.org/10.1016/j.adro.2017.10.007
14. White J, Tai A, Arthur D, et al. Breast Cancer Atlas for Radiation Therapy Planning:
Consensus Definitions. RTOG: Radiation Therapy Oncology Group.
https://www.rtog.org/CoreLab/ContouringAtlases/BreastCancerAtlas.aspx. Accessed June
26, 2016
15. Ansher, S., & Scharf, R. (2001). The Cancer Therapy Evaluation Program (CTEP) at the
National Cancer Institute. Annals of the New York Academy of Sciences. 2001;949(1)
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version 2018.8-25. http://www.cran.r-project.org/package=ordinal/. Accessed October 2,
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.