Multiple case dosimetric evaluation of VMAT scalp irradiation using 3D milled bolus.

Adequate dose homogeneity and full prescription dose delivery to the scalp still remains a dosimetric problem during scalp irradiation due to the anatomical shape of the cranium. Confounding variables such as gravity, the irregular and convex shape of the cranium, air gaps between scalp surface and commercial bolus, and potential inconsistencies in a 3D printed bolus can negatively impact the dose delivered to the scalp surface during scalp irradiation. The purpose of this retrospective case study was to implement the use of a 3D milled rigid bolus technique combined with volumetric modulated arc therapy (VMAT) treatment planning and evaluate the dosimetric efficacy in delivering dose to the surface of the scalp. The 8-patient retrospective case study consisted of patients with a scalp lesion treated using a 3D milled bolus, VMAT, 6 megavoltage (MV) photon beams, and aligned for treatment using daily conebeam computed tomography (CT) and 6° of freedom couch positioning. Dose volume histograms (DVHs) were used to evaluate maximum dose delivered to the planning target volumes (PTVs) while the dose homogeneity index (DHI) was calculated and compared to that of an ideal value of 1. The researchers evaluated the minimum dose delivered to the individual PTVs after plan normalization. The researchers found that the 3D milled bolus coupled with volumetric modulated arc therapy increased surface dose homogeneity, while also increasing the percentage of planning target volumes receiving full prescription dose. With statistically significant results, patient specific 3D milled rigid bolus offers a viable bolus option for treatment of superficial scalp lesions when combined with volumetric modulated arc therapy treatment planning. However, a larger sample size used in a scientific research study across multiple institutions would be desirable to validate these case study findings.