title: Surface and superficial dose dosimetric verification for postmastectomy radiotherapy.
abstract: In patients given postmastectomy radiotherapy (PMRT), the chest wall is a very thin layer of soft tissue with a low-density lung tissue behind. Chest wall treated in this situation with a high-energy photon beam presents a high dosimetric uncertainty region for both calculation and measurement. The purpose of this study was to measure and to evaluate the surface and superficial doses for patients requiring PMRT with different treatment techniques. An elliptic cylinder cork and superflab boluses were used to simulate the lung and the chest wall, respectively. Sets of computed tomography (CT) images with different chest wall thicknesses were acquired for the study phantom. Hypothetical clinical target volumes (CTVs) were outlined and modified to fit a margin of 1-3 mm, depending on the chest wall thickness, away from the surface for the sets of CT images. The planning target volume (PTV) was initially created by expanding an isotropic 3-mm margin from the CTV, and then a margin of 3 mm was shrunk from the phantom surface to avoid artifact-driven results in the beam-let intensity. Treatment techniques using a pair of tangential wedged fields (TWFs) and 4-field intensity-modulated radiation therapy (IMRT) were designed with a prescribed fraction dose (D(p)) of 180 cGy. Superficial dose profiles around the phantom circumference at depths of 0, 1, 2, 3, and 5 mm were obtained for each treatment technique using radiochromic external beam therapy (EBT) films. EBT film exhibits good characteristics for dose measurements in the buildup region. Underdoses at the median and lateral regions of the TWF plans were shown. The dose profiles at shallow depths for the TWF plans show a dose buildup about 3 mm at the median and lateral tangential incident regions with a surface dose of about 52% of D(p). The dose was gradually increased toward the most obliquely tangential angle with a maximum dose of about 118% of D(p.) Dose profiles were more uniform in the PTV region for the 4-F IMRT plans. Most of the PTV region had doses >94% of D(p) at depths >1 mm. The mean surface dose was about 65% of D(p) for the 4-F IMRT plans. The maximum dose for the 4-F IMRT plans was <118.4% of D(p). The application of added bolus has to consider the treatment technique, tumor coverage, and possible skin reactions. For PMRT, if the chest surface and wall are treated adequately, at least 3 mm bolus should be added to the chest wall when tangential beams and 6-MV photon energy are arranged. However, when the surface and superficial regions are not high-risk areas, an IMRT plan with tangential beams and 6-MV photon energy can provide uniform dose distributions within the PTV, spare the skin reaction, and deliver sufficient doses to the chest wall at depths >1 mm.
authors.affiliation: Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei City, Taiwan.
authors.forename: An-Cheng
authors.initials: AC
authors.lastname: Shiau
authors.forename: Min-Chi
authors.initials: MC
authors.lastname: Chiu
authors.forename: Tung-Ho
authors.initials: TH
authors.lastname: Chen
authors.forename: Jeng-Fong
authors.initials: JF
authors.lastname: Chiou
authors.forename: Pei-Wei
authors.initials: PW
authors.lastname: Shueng
authors.forename: Shang-Wen
authors.initials: SW
authors.lastname: Chen
authors.forename: Wei-Li
authors.initials: WL
authors.lastname: Chen
authors.forename: Wei-Peng
authors.initials: WP
authors.lastname: Kuan
mesh_terms: D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000628:therapy*; D005260:Female; D006801:Humans; D008408:Mastectomy; D019047:Phantoms, Imaging; D011874:Radiometry / Q000379:methods*; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D018714:Radiotherapy, Adjuvant / Q000379:methods; D014057:Tomography, X-Ray Computed / Q000295:instrumentation / Q000379:methods*