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Aubrie Rice
Case Study
April 9, 2017
Electron Treatment with .Decimal Bolus for the Left Ear
History of Present Illness: Patient MM is a 66 year old male with an extensive oncologic
history. In June 2015, MM was diagnosed with melanoma of the left lateral thigh, basal cell
carcinoma (BCC) of the right back and also BCC of the left ear. At the time, the patient declined
surgical intervention for these lesions but in mid-June 2015, the left lateral thigh lesion was
excised with negative margins. A chest CT taken at this time also revealed a lung nodule that
was watched and then confirmed to be non-small cell lung cancer (NSCLC) in September 2015.
In October 2015, the patients right back lesion was excised with no residual disease. MM
completed chemo radiation for his NSCLC diagnosis in April 2016. He then had a recurrence in
his right adrenal gland and left hip which was confirmed in September 2016 and systemic
therapy (nivolumab) was started for this in October 2016. Most recently in January 2017, a
physical exam by MMs dermatologist showed a 60% ulceration of the left ear mass that was
originally diagnosed as BCC in June 2015. MM started systemic therapy (5-FU) for his
superficial basal cell carcinoma and was referred to radiation oncology because of his BCC of
the left ear. Restaging scans in January of 2017 showed no evidence of recurrence or
new/progressive disease in the chest and a slight decrease in size of the right adrenal nodule,
decrease in size of the left iliac bone, and no new lymphadenopathy.
The patient was consulted by the radiation oncologist in February 2017 to discuss radiation
therapy treatment options for his cT2NxMx basal cell carcinoma of the left pinna. Treatment
with electrons consisting of 33 treatments was recommended with an estimated local control rate
of 85-90%. The logistics of radiation therapy were discussed with MM including the CT
simulation, treatment planning and start of treatment. Acute and late toxicities were also
discussed with the patient including skin reaction, fatigue, wound healing issues permanent skin
hyperpigmentation, telangiectasia, damage to the underlying bone, cartilage, soft tissue, and
nerves, and secondary malignancy. The patient was then scheduled for CT simulation.
Past Medical History: MM has a past medical history of hypertension, and all oncologic
diagnoses mentioned in the previous section. He has a past surgical history of a hernia repair
(1968), knee surgery (1968), foot surgery (2004), hand restoration surgery for thumb (1974),
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cranioplasty for skull defect (1990), tonsillectomy, diagnostic colonoscopy (2015), skin lesion
excision (2015), lymph node biopsy (10/26/2015), sentinel node intraoperative (10/26/2015),
trunk skin graft (10/26/2015), and bronchoscopy flexible diagnostic (2016).
Social History: MM is single and retired. The patient reports that he quit smoking in May 2016
after smoking one pack of cigarettes per day for 20 years. He has no history of smokeless
tobacco use. MM reports that he drinks 8.4 oz of alcohol per week. Due to the patient being
adopted, there is no known family history.
Current Medications: MM uses the following medications: Fluorouracil 5 % Cream, Lisinopril,
Nivolumab, Prochlorperazine, and Sulfamethoxazole-trimethoprim.
Diagnostic Imaging: The patient was initially diagnosed in June 2015 when the left ear lesion
was discovered and a shave biopsy confirmed basal cell carcinoma. After referral to radiation
oncology for this lesion in January 2017 due to a 60% ulceration, MM underwent restaging scans
on January 25, 2017. A chest CT showed no evidence of recurrence or new/progressive disease.
Also, a CT of the abdomen/pelvis showed a slight decrease in size of the right adrenal nodule,
decrease in size of the left iliac bone, and no new lymphadenopathy.
Radiation Oncologist Recommendations: Due to the superficial location the tumor as well as
the proximity to surrounding critical structures, a single field electron treatment was
recommended by the radiation oncologist. A total of 66 Gy in 33 fractions was the recommended
dose. A local control rate of 85-90% was estimated but it was noted that this may be an
overestimation due to the size and extent of the lesion. Energy was to be determined after CT
simulation and examining the full depth of invasion. The radiation oncologist prescribed bolus
for this plan due to the non-uniformity of the ear and superficial location of the tumor. It was
decided that .decimal bolus would be the best choice since this case fit all of the selection criteria
for .decimal bolus which include: the target volume is less than 6 cm deep, the target volume
varies in thickness throughout the field, critical structures are distal to the target volume and the
patients skin surface has significant variations.1 This type of bolus is generated using a software
provided by .decimal. It is created to vary in thickness along with the patients external anatomy
and the tumor shape in order to conform the 90% isodose line to the planning target volume
(PTV) which has been proven by studies such as one by Kudchadker et al.2 The distal surface of
the bolus conforms to the patients surface and the proximal surface shapes the dose distribution.1
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Patient Setup/Immobilization: MM underwent a CT simulation scan in February 2017. The


patient was placed in the supine position with a B head rest. MMs head was turned to the right
in order to have more access to the patients left ear and the patients head was taped (Figures 1
& 2). A knee sponge was placed under the patients knees for comfort. The radiation oncologist
also wired around the borders of the lesion with a radiopaque wire (Figure 3).
Anatomical Contouring: Upon completion of the CT simulation, the CT data set was sent to the
Eclipse treatment planning system (TPS). The dosimetrist contoured most of the organs at risk
(OR) including the brain, brainstem, cochleae, eyes, lenses, optic nerves, and spinal cord. The
dosimetrist also contoured the body which will be important in the following section when
discussing the .decimal bolus. The physician contoured the optic chiasm and parotid glands as
well as defining the gross tumor volume (GTV) and PTV structures.
Beam Isocenter/Arrangement: After receiving the final contours and target volumes from the
physician, the planning process was started. The plan was created for a Varian TrueBeam linear
accelerator. A single beam was placed by the medical dosimetrist after determining a beam angle
that the electron cone and the patients surface would be in the same plane (enface). A gantry
angle of 55 degrees was selected with no couch rotation needed (Figure 4). An electron cone size
was then selected that would encompass the entire PTV volume (10 x 10) (Figure 5). Isocenter
was placed so that the source to skin distance (SSD) to the patients skin was 110 cm (Figures 6-
8). An electron cone cutout was created by the medical dosimetrist using the TPS by placing a 5
cm margin around the PTV (Figure 5).
Next, it was time to create the .decimal bolus structure, but first the medical dosimetrist needed
to choose an energy. As Khan3 states, choosing beam energy is more critical for electrons than
for photons since dose decreases rapidly after the 90% isodose line. When in doubt, choosing a
higher energy to make sure the target gets coverage is the guiding principle.3 Since .decimal can
increase the thickness of the bolus covering the PTV, it can compensate for the higher energy in
order to match the 90% isodose line to the PTV.1 At its deepest, the PTV was around 3 cm deep.
As stated by Khan3, the depth at which electrons deliver a dose to the 90% line is one-fourth of
the electron energy. Thus, an electron energy of 13 MeV would deliver 90% to a 4 cm depth.3
The medical dosimetrist chose an electron beam energy of 15 MeV. All structures and the
electron cutout were then exported to the .decimal software and the energy and cone size were
entered into the program. A bolus structure was then created using this information and exported
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back into the TPS. As mentioned previously, the .decimal software uses this information to
create a bolus structure that will conform the 90% isodose line to the target.2
Treatment Planning: After the bolus structure was imported into the Eclipse TPS from the
.decimal software, the treatment planning process could now continue on the next steps. As
mentioned previously, this plan was created for a Varian TrueBeam linear accelerator. The plan
was calculated to deliver 66 Gy in 2 Gy fractions and normalized to the PTV (100% of the dose
covering 95% of the target volume). A Monte Carlo calculation (EMC) was completed by the
TPS by simulating the transport of millions of electrons through the beam path. Using the
fundamental laws of physics, it simulates the probability distributions of each of the particle
interactions.4
Dose distribution was then evaluated and planning volumes along with OR were evaluated on the
DVH (Figures 9-12). The PTV was to receive 100% of the dose to 95% of the volume. Since the
plan was normalized to this structure the PTV did in fact meet this constraint. In addition, the OR
also had constraints from the physician. The brainstem was to receive a maximum dose less than
50 Gy. On the plan created, the maximum dose was 18.5 Gy. The cochleae were to receive a
mean dose less than 20 Gy and a maximum dose less than 25 Gy. On the final plan, the mean
dose to the right cochlea was 0.91 Gy and the mean dose to the left was 6.24 Gy while the
maximum dose to the right cochlea was 1.03 Gy and the maximum dose to the left was 15.25
Gy. The eyes were to receive a maximum dose less than 45 Gy and the volume receiving 35 Gy
(V35) was to be less than 5%. The constraints were also met with the maximum dose to the right
and left eyes being 0.68 Gy and 0.64 Gy, respectively and the V35 of the right and left eyes were
both 0%. The optic nerves were to receive a maximum dose less than 45 Gy and both volumes
met this constraint at 0.74 Gy (right) and 0.86 Gy (left). The spinal cord was to receive a
maximum dose of less than 45 Gy. On the plan, the maximum dose to the spinal cord was 1.59
Gy. The optic chiasm was to receive a maximum dose of less than 45 Gy. Lastly, the parotid
glands were to receive a mean dose of less than 26 Gy and met at 0.96 Gy. While the right
parotid met at 0.8 Gy, the left parotid was partly included in the physicians PTV (Figures 13-14)
and did not meet this constraint with a mean dose of 28.2 Gy.
The Plan (prescription): The radiation oncologist had already prescribed 66 Gy to be delivered
in 2 Gy fractions. Now that planning was complete, the physician reviewed the plan. The
radiation oncologist agreed upon 15MeV for the prescription and approved the plan.
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Verification CT Scan with Bolus: After receiving the .decimal bolus structure, the patient was
set up in treatment position again with the bolus structure placed. An aquaplast mask was created
due to the large size and resulting weight of the bolus and also the sloping surface it was to be
positioned on (Figure 15). The mask helped to keep the patients head stable and also helped to
keep the bolus in place. MM was rescanned in this position and a verification plan was created to
ensure that the dose distribution correlated with the plan on the original CT scan.
Quality Assurance/Physics Check: After the bolus structure with the aquaplast mask had been
verified by the verification plan, a monitor unit (MU) check was performed by the medical
dosimetrist using the RadCalc program. This calculation was then checked by the physics team.
This check passed with a 0.1% difference which falls within our departments tolerance of 3%.
Conclusion: This electron treatment plan with .decimal bolus provided a couple of challenges
for the planning medical dosimetrist and also the physician. The first challenge was creating a
setup for the patient that was reproducible, manageable for the patient, as well as one in which
the tumor was accessible for treatment. Once this was accomplished, an enface beam had to be
chosen. Also, when choosing the energy to use in this situation, the planning dosimetrist needed
to know rules of thumb for electrons. While keeping in mind the potential thickness of the bolus
structure, the dosimetrist did as Khan3 stated and chose a higher energy than needed. The next
challenge came after the .decimal bolus arrived. Upon setting the patient up for the verification
scan, it was noted that the weight of the bolus along with the sloping surface it was being placed
on made this a difficult position for the patient to tolerate and therefore was not reproducible.
This challenge was solved by creating an aquaplast mask that surrounded the bolus structures
edges, helping to hold the bolus and the patients head position in place.
For me, this was kind of a difficult case to approach. Before reviewing this case, I was familiar
with electron interactions, isodose distributions, and rules of thumb but I had never been directly
involved with planning a .decimal bolus case. Due to this, it was difficult for me to explain the
steps of the planning process. After sitting down with my clinical preceptor and asking questions,
things were a lot more clear and easy to understand. I learned about the software we use to create
the .decimal bolus and how this is exported into the treatment plan and ordered for treatment. I
also learned the advantages of this type of bolus with irregular surfaces and varying tumor depth.
Though it did present with some complications, the .decimal bolus structure helped to produce a
plan that the 95% isodose line could conform the PTV which is ideal. Without this structure, it
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would have been difficult to produce a plan of the same quality. In the end, this bolus structure
and the resulting plan were the best choice for the overall benefit of patient.
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References
1. Kavanaugh JA. Clinical Use of Bolus Electron Conformal Therapy (BECT) in the Treatment
of Shallow and Irregularly Shaped Tumors. Lecture presented: AAMD Meeting; June 01,
2014; Seattle, WA.
2. Kudchadker RJ, Antolak JA, Morrison WH, Wong PF, Hogstrom KR. Utilization of custom
electron bolus in head and neck radiotherapy. J Appl Clin Med Phys. 2003;4(4):321-333.
http://dx.doi.org/10.1120/1.1621494
3. Khan, FM. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott Williams
& Wilkins; 2014:264-272.
4. Khan, FM. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2012:131-132.
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Figures

Figure 1. Patient setup in CT simulation in supine position with arms at sides and knee sponge.

Figure 2. Patient setup: head turned to right and immobilized using tape.
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Figure 3. Lesion was wired by the radiation oncologist during CT simulation.

G55

Figure 4. A gantry angle of 55 is shown here in the axial view.


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Figure 5. The 10 x 10 cone and cutout encompassing PTV.

ISOCENTER
@ 100 SAD

110 cm to
patients surface

Figure 6. Isocenter placement - Extended distance treatment at 110 cm SSD.


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Figure 7. Isocenter placement after bolus creation in the AP setup view.

Figure 8. Isocenter placement from the beams eye view (BEV).


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Figure 9. Dose distribution at isocenter.

Figure 10. Dose distribution in the coronal view.


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Figure 11. Dose distribution in the sagittal view.

PTV

95%

Left Parotid

Left Cochlea

6600
0
Figure 12. The DVH demonstrates that the PTV is getting prescription coverage (95% of PTV
receiving 66 Gy) and that most of the OR are receiving an extremely low dose except the left
cochlea and left parotid.
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Figure 13: Beams eye view (BEV) of treatment field showing overlap of the PTV and the left
Parotid.

Figure 14: Axial view of the treatment field showing PTV and left parotid overlap including
dose distribution.
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Figure 15: Patient setup after aquaplast mask was created, prior to verification scan.