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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
thicknesses 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 (dmax), which can result in an under-
dosage of the skin surface, and poses a risk for local recurrence.2,3 To counteract the loss of
prescription dose to the skin surface in the treatment area, a TEB is often used.2-5 Tissue
equivalent bolus may be composed of various materials including SuperStuff, Elasto-Gel and
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 decreases the depth of dmax to the body surface, effectively
treating the skin with prescription dose.
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 in varying degrees of radiation
dermatitis 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.
In order 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.
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The borders for both the tangents and supraclavicular field were designed to include the
entire PTV, the axillary nodal levels 1-3, and supraclavicular lymph nodes. At the time of
simulation, the physicians placed radiopaque wiring to define the intended treatment borders of
the patient’s chestwall. 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 the thyro-cricoid groove. The lateral border started at the
acromioclavicular joint, bisecting the humeral head, while excluding as much of the shoulder as
possible. Superiorly, the border extended across the neck and trapezius muscle to the acromial
process to ensure the entire supraclavicular fossa was included. Inferiorly the border matched
the superior edge of the tangential fields.
The only aspect of the treatment plan that varied between patients was the thickness and
frequency of the bolus used. Facility 1 data used 3 mm bolus daily with either Superflab or
Elasto-gel, while facility 2 used 5 mm bolus every other day with Elasto-gel. At both facilities,
bolus was applied in the TPS rather than during the CT simulation. In the TPS, the bolus was
drawn to cover the tangential treatment fields entirely and abut the inferior border of the
supraclavicular field. A 3D skin rendering containing the tangent light fields and bolus was
provided to the radiation therapists for visual guidance regarding bolus placement for each
patient. At both facilities, the supraclavicular field was treated first without bolus in place,
followed by the tangential fields with the bolus. In each case, 1 standard sheet of bolus material
(30 cm x 30 cm) was used to encompass the entirety of each tangent field. The bolus was
adjusted by the radiation therapists as needed between the medial and lateral treatment fields by
using the light field to ensure complete bolus coverage.
Results
As each patient progressed through the treatment regimen, they had weekly appointments
with their provider’s team to assess progress through treatment and address any side effects. At
this time, the provider assessed the presence or absence of radiation dermatitis according to the
Common Toxicity Report (CTC) published by the Cancer Therapy Evaluation Program of the
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National Cancer Institute (NCI).15 The scale used to measure 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 patient’s score, according to the scale, was recorded weekly.
For facility 1 during the first week of treatment, 91% of patients reported no skin reaction
with 9% scoring a 1 on the radiation dermatitis index. 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. The fifth and final week, 22% of patients scored a 1 and 78% scored a 2. One
patient terminated treatment at 4,800cGy due to radiation dermatitis.
In contrast, during the first week, 85% of patients at facility 2 reported no skin reaction
with 15% scoring a 1 on the radiation dermatitis index. In the second week of treatment, 55%
indicated no skin reaction with 45% of patients scored a 1 on the radiation dermatitis index. For
week 3, 20% of patients had no skin reaction, 70% scored a 1 and 10% scored a 2. During week
4, 70% scored a 1, 25% scored a 2, and 1 patient was recorded as having no reaction even though
the previous week they scored a 1 on the index. During the fifth week, 35% of patients scored a 1
while 65% scored a 2.
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 (Figures 1 and 2).16 The overall mean
score for all weeks for facility 1 was 0.93 and 0.87 for facility 2.
Discussion
When the data from each facility was evaluated, the high p-value result of 0.368
demonstrated that there was no statistically significant difference between the 2 bolus application
techniques. This outcome could be attributed to different factors including bolus thickness
versus surface dose, bolus application frequency, and other study variables. A review of the
literature on TEB, skin surface dose, and radiation dermatitis provided evidence to support a
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hypothesis that a lack of difference between the bolus techniques used in this study could be
attributed to an offset effect that is explained herein.
For TEB, a commonly observed outcome among current studies showed a direct
correlation between increasing bolus thickness and increasing skin surface dose.1,3,5,8 Because the
chestwall is such a thin structure, bolus application is necessary to provide adequate coverage
when using low energy photon beams. The presence of radiation dermatitis due to bolus
application was clearly supported by this study as there was an obvious increasing trend in
radiation dermatitis progression as patients advanced through treatment.
Another important consideration is the bolus application frequency. In an extensive
study by Andic et al,4 it was determined that an increase in bolus application frequency had a
direct correlation with skin toxicity.4 Therefore researchers were able to conclude, not only had
the initial use of bolus demonstrated an increase in skin toxicity, but the number of times the
bolus was used also showed an increase in skin toxicity.
Although not considered statistically significant, this study had 1 contrasting outcome;
facility 1 showed a slightly higher overall mean in radiation dermatitis when compared to facility
2 (Figure 2). After further evaluation, there were some noticeable variables that could also have
impacted the study’s results including differing bolus manufacturers and differing bolus
application frequencies with different bolus thicknesses. Although bolus is designed with the
intention of having a density of 1.0 g/ml, there may be some slight variances between products
produced at different manufacturing companies.8,9 In this study, 2 different bolus manufacturers
were used. In addition, this study incorporated both a variation in bolus thickness and frequency
in treatment application which the researchers hypothesize offset any significant difference in
skin toxicity. If the frequencies of bolus application differed yet the bolus thickness remained the
same between facilities, then a more measurable difference may have been found.
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 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
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suggestion would be to track radiation dermatitis 1-2 weeks after treatment has ended to observe
the radiotherapeutic effects still occurring post-treatment
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. 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. A larger and more diverse
study sample size may be necessary to obtain more substantial results. If comparable results are
determined 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 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
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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
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September 16, 2018.
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wax bolus in radiation therapy of irregular surfaces. Med Dosim. 1996;21(3):155-157.
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Phys. 2012;84(3)S247. https://dx.doi.org/10.1016/j.ijrobp.2012.07.641
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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.
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.
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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.