title: Evaluation of impact of an external breast shield (FlexiShield) in electronic brachytherapy for breast IORT: A phantom study.
abstract: To investigate Axxent (iCAD, Inc., San Jose, CA) electronic brachytherapy balloon deformation and its dosimetric impact because of an external flexible shield (FlexiShield [FS]; iCAD, Inc.).
  
  
  
  Prostheses breast tissue phantom overlaid three spherical balloon applicators to simulate three clinical scenarios depending on minimum skin-to-balloon surface spacing (SS): balloon with SS of 2 cm, 1 cm, and balloon with 1 cm SS and touching the chest wall. Two sets of megavoltage CT (MVCT) scans were obtained with or without FS for 15 different sizes of balloons. For 45 pairs of MVCT scans, balloon deformation was measured in superior-inferior (dSI) dimension on coronal and sagittal planes and anterior-posterior (dAP) and lateral (dLAT) dimensions on the equatorial plane of balloon. SS was also compared. A treatment plan was made on each MVCT scan. Doses at four balloon surface points and skin were compared. Conformity index value was also compared to evaluate three-dimensional dose distribution. Clinically, 20 Gy was prescribed to the surface of balloon.
  
  
  
  Balloon deformation was observed with compression in SI and AP dimensions and expansion in lateral dimension. Average SI compression was 0.5 mm. Average dLat- dAPwas 2.4 mm, which resulted in elevated point doses at AP dimension by 10.8% of prescribed dose and reduced point doses at lateral dimension by 4.6%. FS decreased SS by 1.8 mm, increasing skin dose by 1.2 Gy, on average. Conformity index value was decreased from 0.922 to 0.908, on average.
  
  
  
  This phantom study demonstrates that use of skin shielding during breast intraoperative radiation therapy can cause balloon deformation and SS reduction, resulting in dosimetric changes that are disregarded in current practice.
authors.affiliation: Department of Radiation Oncology, The University of Arizona, Tucson, AZ. Electronic address: yongbokkim@email.arizona.edu.
authors.forename: Yongbok
authors.initials: Y
authors.lastname: Kim
authors.affiliation: Department of Radiation Oncology, The University of Arizona, Tucson, AZ.
authors.forename: Jason Wei-Yeong
authors.initials: JW
authors.lastname: Huynh
authors.affiliation: Department of Radiation Oncology, The University of Arizona, Tucson, AZ.
authors.forename: Victor J
authors.initials: VJ
authors.lastname: Gonzalez
mesh_terms: D001918:Brachytherapy / Q000295:instrumentation* / Q000379:methods; D001940:Breast; D001943:Breast Neoplasms / Q000532:radiotherapy* / Q000601:surgery; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D019047:Phantoms, Imaging; D011829:Radiation Dosage; D011879:Radiotherapy Dosage; D012867:Skin; D014057:Tomography, X-Ray Computed
keywords: Dose change; Electronic brachytherapy (eBT); FlexiShield (FS); Inflatable balloon deformation; Intraoperative radiation therapy (IORT); Skin spacing reduction