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Research Proposal (Quantitative)

Title: Dosimetric evaluation of volumetric modulated arc therapy (VMAT) treatment planning
combined with 3D milled bolus for patients receiving total and partial scalp irradiation

Literature Review Summary:

Advancements such as the use of Intensity Modulated Radiation Therapy (IMRT) and
Volumetric Modulated Arc Therapy (VMAT) have helped to improve the treatment delivery
methods used for many disease sites, especially for those who have scalp lesions. Ostheimer et
al1 states that IMRT and VMAT have shown promise in delivering effective radiation treatments
to total scalp patients for those who have squamous cell carcinoma, mycosis fungoides,
lymphoma of the scalp, or an angiosarcoma diagnosis. Although IMRT and VMAT techniques
are capable of being used as a treatment method, another study completed by Kai et al2
introduced the difficulty associated with getting uniform dose to the target while sparing organs
at risk (OAR) such as the brain and optical structures. Such difficulties in achieving a uniform
dose distribution is due in part to the natural convex shape of the cranium.3

To achieve a more desirable and homogenous dose distribution, facilities have begun
experimenting with different bolus methods coupled with the use of IMRT or VMAT
technologies over the previously common method of photon/electron matching for total scalp
irradiation.1 One way to increase the accuracy of the surface dose distribution is by decreasing
the air gap between the bolus and the skin.4 However, decreasing the air gap in the clinical setting
is not possible using a commercial flat bolus on these scalp patients due to confounding variables
like gravity and irregular surface contours caused by structures like the nose and ears.5 Instead,
facilities have developed a 3D printed bolus specifically for use on the scalp.6,7 Rakici et al8
demonstrated that the dose distribution, homogeneity, and conformity index improved by using a
3D bolus with VMAT or IMRT.8 An improvement in plan homogeneity and conformity helps
deliver adequate dose to the tumor while also reducing low dose continuation into underlying
OAR much like that of the brain and sensitive optic structures.

The problem is that due to the anatomical shape of the cranium, adequate dose
homogeneity and full prescription dose delivery to the scalp still remains a dosimetric problem
during scalp irradiation. The purpose of this research study is to introduce a 3D milled rigid
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bolus technique combined with VMAT treatment planning to evaluate the dosimetric efficacy in
delivering dose to the surface of the scalp.

Problem Statement

Due to the anatomical shape of the cranium, adequate dose homogeneity and full prescription
dose delivery to the scalp still remains a dosimetric problem during scalp irradiation.

Purpose Statement

The purpose of this research study is to introduce a 3D milled rigid bolus technique combined
with VMAT treatment planning to evaluate the dosimetric efficacy in delivering dose to the
surface of the scalp.

Hypothesis

The research hypothesis (H1) is that using a 3D milled rigid bolus with VMAT will increase
surface dose homogeneity. The null hypothesis (H10) is that using a 3D milled rigid bolus with
VMAT will decrease surface dose homogeneity. Research hypothesis (H2) is that using a 3D
milled rigid bolus with VMAT will increase the percentage of planning target volume (PTV)
receiving prescription dose. Null hypothesis (H20) is that using a 3D milled rigid bolus with
VMAT will decrease the percentage of PTV receiving prescription dose.

Methods and Materials

Patient Selection

The 8 patient sample size is made up of both male and female genders. Only patients who were
treated with a 3D milled rigid 1 cm uniform thickness bolus for a scalp lesion were chosen for
this study. Each patient was treated with the same immobilization technique: head first, supine,
conformal board, two 1 mm shims under headrest, Silverman head rest, custom molded headrest
on top of supporting head rest, and then a patient specific 3D milled rigid 1 cm uniform thickness
bolus.

Planning Procedures

The treatment plans were all planned using Varian’s Eclipse Version 13.7 & 15.6 treatment
planning system (TPS). Each plan was approached with a VMAT technique utilizing 6MV
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photon energy and it was delivered on a Varian TrueBeam linear accelerator to a dose of 60 to 66
Gy in 30 to 33 fractions covering 95% or greater of the PTV. The PTV was created by the
radiation oncologist wiring the clinical tumor volume (CTV) and then a 2 cm margin was created
around it. Brain contours will be created using the auto contouring tool and optic structures will
be contoured by the planning dosimetrist following the Radiation Therapy Oncology Group
(RTOG) 1106 guidelines. All contoured structures are approved by the radiation oncologist prior
to planning commencement. In-vivo measurements were completed within the first 3 fractions
and a daily cone beam computed tomography (CBCT) was completed allowing for 6 degrees of
freedom (6DOF) patient positioning corrections using the planning CT’s digitally reconstructed
radiographs (DRR).

Evaluated Variables

Researchers will evaluate the dose variation between the planned dose and delivered dose to the
scalp using the in-vivo measurements taken between the first three fractions using optically
stimulated luminescence device’s (OSLD) placed at various locations on the scalp. All of the
measurements will be averaged to get the mean dose delivered and then compared to the
prescription dose. Evaluation of the planning method to increase homogeneity will include the
use of the TPS modeling of the VMAT plan utilizing individualized jaw-blocking and flash
creation within the bolus material itself using expansion structures off of the PTV. This
information will be confirmed with the in-vivo measurements.
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References

1. Ostheimer C, Hübsch P, Janich M, Gerlach R, Vordermark D. Dosimetric comparison of

intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy
(VMAT) in total scalp irradiation: a single institutional experience. Radiat Oncol J.
2016;34(4):313–321. http://dx.doi.org/10.3857/roj.2016.01935
2. Kai Y, Toya R, Saito T, et al. Plan quality and delivery time comparisons between
volumetric modulated arc therapy and intensity modulated radiation therapy for scalp
angiosarcoma: a planning study. J Med Radiat Sci. 2018;65(1):39-47.
http://dx.doi.org/10.1002/jmrs.239
3. Mail N, Al-Ghamdi SM, Chantel C, Sedhu F, Rana A, Saoudi A. Customized double-
shell immobilization device combined with vmat radiation treatment of basosquamous
cell carcinoma of the scalp. J Appl Clin Med Phys. 2019;20(2):84-93.
http://dx.doi.org/10.1002/acm2.12536
4. Kong Y, Yan T, Sun Y, et al. A dosimetric study on the use of 3D-printed customized
boluses in photon therapy: A hydrogel and silica gel study. J Appl Clin Med Phys.
2019;20(1):348–355. http://dx.doi.org/10.1002/acm2.12489
5. Fujimoto K, Shiinoki T, Yuasa Y, Hanazawa H, Shibuya K. Efficacy of patient-specific
bolus created using three-dimensional printing technique in photon radiotherapy. Phys
Med. 2017;38:1-9. http://dx.doi.org/10.1016j.ejmp.2017.04.023
6. New findings reported from m.d. anderson cancer center describe advances in medical
physics (development and validation of a 3d-printed bolus cap for total scalp irradiation).
Phys Wk. 2019;696:696-696.
7. Baltz GC, Chi PM, Wong PF, et al. Development and validation of a 3D-printed bolus
cap for total scalp irradiation. J Appl Clin Med Phys. 2019;20(3):89–96.
http://dx.doi.org/10.1002/acm2.12552
8. Rakici SY, ÇINAR Y, EREN M. Total scalp irradiation: the comparison of five different
plans using volumetric modulated arc therapy- simultaneous integrated boost (VMAT-
SIB) technique. Turk J Oncol. 2017;32(3):106-115.
http://dx.doi.org/10.5505/tjo.2017.1609