Radiation Physics and Chemistry 174 (2020) 108952

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Radiation Physics and Chemistry

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Construction and performance evaluation of a buildup bolus for breast T

intraoperative electron radiotherapy
Seyed Hamid Zoljalali Moghaddama, Hamid Reza Baghanib, Seyed Rabi Mahdavia,∗
a
Medical Physics Department, Iran University of Medical Sciences, Hemmat Exp. Way, P.O. 14496141525, Tehran, Iran
b
Physics Department, Hakim Sabzevari University, Daneshgah Blvd, P. O. 617976487, Sabzevar, Iran

A R T I C LE I N FO A B S T R A C T

Keywords: The under-dosage of the target surface in breast intraoperative electron radiotherapy (IOERT) is one of the main
Breast cancer concerns which can be compensated through employing a buildup bolus. The aim of this study is to design and
IOERT introduce a new buildup bolus for breast IOERT to improve both surface dose and dose uniformity within the
Buildup bolus target.
PLA (Polylactic acid)
PLA (Polylactic Acid) material was selected to construct the flat panel bolus. Two different infill percentages
Dosimetry
of 60% and 100% were considered for bolus printing and their dosimetric characteristics were evaluated through
Monte Carlo simulation and based on the closer matching to those of water, the best filling percentage was
selected. Then, the bolus was constructed by a Diane K36-S 3D printer and its dosimetric performance in in-
traoperative electron beam was evaluated through ionometric dosimetry inside the developed bolus. All of the
irradiations were performed by LIAC12 dedicated IOERT accelerator and the dosimetric data were obtained by
Advanced Markus dosimeter.
The results showed that the PLA bolus with 100% infill percentage would have the best performance as a
buildup bolus. The measured PDD curves inside the constructed PLA bolus at different energies had desirable
accordance with those measured inside the water.
Based on the obtained results, it can be concluded that the dosimetric characteristics of designed PLA bolus
would be satisfactorily in breast IOERT. This toxic-free PLA based bolus can be considered for surface dose
enhancement and dose uniformity improvement during breast IOERT.

1. Introduction
Breast cancer is the most common cancer type in women and one of
the main causes of death. The mortality rate of breast cancer has de-
clined significantly since 1975 due to increased use of advanced
mammography systems as well as the use of radiotherapy as a com-
plementary therapy. The use of radiotherapy in breast cancer treatment
showed that the rate of tumor recurrence is significantly reduced (Biggs
et al., 2011).
Nowadays, intraoperative radiotherapy (IORT) has been introduced
as a useful treatment modality for partial breast irradiation (PBI) in
patients with early-stage breast cancer (Willett et al., 2007). One of the
famous techniques for IORT is the intraoperative electron radiotherapy
(IOERT). In this method, a high single fraction of radiation dose is
delivered to the patient by high energy electrons ranging from 6 to
12 MeV energy (Baghani et al., 2019a).
In breast IOERT, the solid tumor is removed by the surgeon and the
remaining tumor bed is separated from the superficial pectoral muscles
through a double-layered shielding disk. Then, the tumor bed, which is
upon the radio-protective disk, is irradiated by single radiation doses of
up to 21 Gy (Baghani et al., 2018; Intra et al., 2006). One of the ad-
vantages of IOERT is the direct visualization of the organs at risks
(OARs) and capability of removing them from the radiation field.
Therefore, only the interesting target area is irradiated by such high
energy electron beams (Baghani et al., 2019b).
The surface of the tumor bed is considered as a part of target during
the breast IOERT. The isodose prescription in this treatment technique
is planned in such a way that the 90% isodose line fully covers the
target thickness (Ciocca et al., 2003). But, unfortunately, the percen-
tage surface dose is usually lower than 90%, especially at lower in-
traoperative electron energies (less than 10 MeV). As a consequence,
the surface will be under-dosed after the treatment. To avoid this pro-
blem, lower isodose prescription level can be used for patient irradia-
tion, in expense of increased number of administered Monitor Units

∗
Corresponding author.
E-mail address: srmahdavi@hotmail.com (S.R. Mahdavi).

https://doi.org/10.1016/j.radphyschem.2020.108952
Received 25 June 2019; Received in revised form 23 April 2020; Accepted 25 April 2020
Available online 01 May 2020
0969-806X/ © 2020 Elsevier Ltd. All rights reserved.
S.H. Zoljalali Moghaddam, et al.
(MU), hot points formation within the target volume, as well as the
higher received dose by the srounding and undelying healthy tissues. As
an alternative method, one can introduce a buildup bolus during the
treatment to increase the surface dose and also keep the isodose pre-
scription level as high as possible.
Multiple studies are published regarding the design and usage of
bolus in external radiotherapy to improve the compliance with irre-
gular surfaces and also obtain a desirable dose distribution within the
target (Burleson et al., 2015; Lukowiak et al., 2017; Park et al., 2016; Su
et al., 2014). Although the usability of buildup bolus for external
radiotherapy techniques has been widely investigated, limited re-
searches exist about the application of the bolus in intraoperative
electron radiotherapy (Petoukhova et al., 2017). This issue is likely dut
to the routine and wide employment of the wet gauze as the buildup
bolus for breast IOERT purposes (Intra et al., 2006). In addition there is
no report about design and application of 3D printable bolus materials
for intraoperative electron radiotherapy. Therefore, the aim of this
study is to design and construct a biocompatible buildup bolus for ap-
plication in IOERT and surface dose enhancement during the breast
treatment.
2. Materials and methods
2.1. LIAC12 dedicated accelerator
The intraoperative electron beam from a LIAC12 dedicated IOERT
accelerator (Sordina- Vicenza, Italy) was used in this study. This light
accelerator is mobile and can produce electron beam with energies of 6,
8, 10 and 12 MeV. Furthermore, this machine is equipped with some
dedicated cylindrical applicators which can be attached to the end of
LIAC head for electron beam collimation and delivery. The 10 cm
diameter applicator, known as reference applicator, was employed for
electron irradiation (Baghani et al., 2015; Iaccarino et al., 2011).
2.2. Bolus design and construction
Bolus is a soft and flexible material with tissue equivalent properties
that is used to increase the surface dose and reduce the dose in depth
(buildup bolus) as well as compensate the missed tissues at irregular
surfaces (Ricotti et al., 2016). Due to the employment of the limited
electron energies in intraoperative electron radiotherapy and decre-
ment of surface dose, applying a buildup bolus for surface dose en-
hancement is highly recommended.
Recently, the use of three-dimensional (3D) printing technology in
bolus construction for radiotherapy purposes has been highly increased.
The same technology was also employed in the current study to design
and print the interested boluses. Commercially available 3D printers
use two main materials: PLA (Polylactic Acid) and ABS (Acrylonitrile
Butadiene Styrene) as the printable bolus material (Alssabbagh et al.,
2017). Because these materials are prepared in the form of separate
filaments, the fused deposition modeling (FDM) by 3D printing tech-
nology is required to construct them as solid and volume samples with
different dimensions and infill percentages. Otherwise, a simple cutting
procedure could be followed for construction and preparing the inter-
esting buildup bolus.
In contrast to PLA, ABS has some toxic properties which limit its
application in IORT due to the increased risk of patient infection.
Therefore, the PLA material was considered as the favored material for
the construction of the buildup bolus (Wojtyla et al., 2017). The ele-
mental composition of the PLA material is reported in Table 1
(Alssabbagh et al., 2017).
A low-cost 3D printer (DAYAN K36-S) was used in this study to
make the interested tissue equivalent buildup boluses. This 3D printer
uses the fused deposition modeling (FDM) technology and can print
volumes with the dimensions up to 30 × 30 × 20 cm3.
The boluses were designed by an open-source and browser-based 3D
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Radiation Physics and Chemistry 174 (2020) 108952
Table 1
Elemental constitutes of PLA material and their corresponding mass percen-
tages in composition according to the reported data by Alssabbagh et al. (2017).
Elemental constitute Mass percentage in composition (%)
H 5.29
C 51.86
O 42.61
S 0.12
K 0.11
design tool (TinkerCAD, Autodesk Inc). The models were processed
with the proprietary software application of the 3D printer (Peak-3D
version 1.2) which converts the digital 3D model to printing instruction
of the 3D printer. Boluses were printed vertically on the top of a dis-
posable material raft ensuring more adhesion to the printing plate and
preventing the warping of the printed object during the printing pro-
cess. The ratio of the printed materials to the volume of air is defined by
the infill percentage parameter which can range from 10% to 100%.
Once selected, the infill value would be constant throughout the process
and cannot be changed in the middle of the print. The final constructed
boluses were flat ones with 2 mm thickness. A circula sapmle of 3D
printed PLA bolus with 6 cm diameter has been shown shown in Fig. 1.
2.3. Monte Carlo simulation
According to Ricotti et al. study (2017), the infill percentages above
60% for constructing the bolus by a 3D printer would show a desirable
bolus performance. In order to find the more appropriate filling per-
centage, two infill percentages of 60% and 100% were modeled by
Monte Carlo method and acquired percentage depth dose (PDD) data in
buildup region for different intraoperative electron energies were
compared with those obtained inside the water. Then, the more suitable
filling percentage was found based on the better accordance with water
dosimetry data. The depths below buildup region, in breast IOERT, are
frequently shielded through a radioprotection disk so that the rest of
PDD curve falls to zero behind the shielding disk (Robatjazi et al., 2018;
Russo et al., 2012). That is why the evaluated depths were limited to
the buildup region of different electron energies. The density of the
simulated PLAs was equal to 1.2 g/cm3 and 0.97 g/cm3 for 100% and
60% filling percentage, respectively.
To do so, at first the LIAC head along with the reference applicator
(10 cm diameter applicator) were simulated by the BEAMnrc Monte
Carlo code (Rogers et al., 1995) and the validity of the simulated model
was evaluated through comparing the PDD data with measured ones.
Then, the simulated PLA boluses with different filling percentages (60%
and 100%) were irradiated by the simulated LIAC head at different
electron energies and obtained PDD data along the clinical axis of the
reference applicator were compared with those calculated inside the
water.
Different components of LIAC head including vacuum exit window,
scattering foil, monitor ionization chambers and subsequent protective
layer as well as the connected applicator were simulated by different
predefined modules in BEAMnrc Monte Carlo code. List of employed
modules for modeling the different components of the LIAC head and
corresponding filling materials are presented in Table 2.
Spatial intensity profile of impinging electron beam on the exit
window was considered as a Gaussian distribution with 1 mm FWHM
(Full Width at Half Maximum) (Iaccarino et al., 2011). In addition, the
mean angular distribution of primary incident electrons was set to zero.
The phase space files related to the different electron energies were
scored at the bottom of the reference applicator. These phase space files
involve the various physical characteristics of different crossing parti-
cles (electron and photon) from scoring plane including energy, posi-
tion and direction parameters. 2 × 109 histories were followed to
generate the corresponding phase space files at different electron
S.H. Zoljalali Moghaddam, et al. Radiation Physics and Chemistry 174 (2020) 108952

Fig. 1. The constructed circular PLA boluses with 2 mm thickness and diameter of 6 cm which can be used along with the cylindrical applicator diameters up to 5 cm.

Table 2 boluses, the PDD curves along the clinical axis of the reference appli-
The list of employed component modules and their filling materials for LIAC cator at different electron energies (6, 8, 10 and 12 MeV) were mea-
head simulation. sured inside the bolus and obtained data were quantitaiely comared
LIAC component Component module Filling material with the measured PDDs inside the water through gamma analysis. The
(CM) gamma index values lower than one are considered as the agreement
between the results (Low et al., 1998). Due to the employment of a
Titanium exit window SLAB Titanium (TI)
shielding disk during the breast IOERT, PDDs will decrease to zero
Scattering foil SLAB Aluminum (AL)
Monitor unit chamber CHAMBER Aluminum (AL), Air (AIR) and
behind the shielding disk. Considering the fact that the shielding disk is
Mylar (MYLAR) often placed at the depth of R90 (depth of 90% isodose level), the PDD
Applicator FLATFILT PMMA data inside the PLA were only obtained up to the measured R90 depth
Surrounding structures FLATFILT Steel (STEEL) and Peek (PEEK) inside the water. R90 values for different electron energies of LIAC12
accelerator are reported in Table 3 (Robatjazi et al., 2018).
To measure the PDD curve inside the bolus, an Advanced Markus
energies. Furthermore, the cut-off energy during the transportation of
ionization chamber (Type 34045, PTW-Freiburg, Germany) was em-
the electron and photon (ECUT and PCUT) was equal to 0.521 MeV and
ployed. A PLA-made slab (with 1.5 cm thickness) was prepared and a
0.01 MeV, respectively.
dedicated cylindrical hollow was inserted inside the slab to serve as the
PDD data were calculated through importing the generated phase
chamber holder. The ionization chamber was placed inside the holder
space files by the BEAMnrc code at different energies to the DOSXYZnrc
and PLA slabs with 2 mm thickness were put upon the chamber. Then,
code and scoring the absorbed dose inside the cubic voxels with the
the chamber was irradiated three times by a given electron energy. This
dimensions of 2 × 2 × 2 mm3 located along the clinical axis of the
procedure was repeated until the chamber was placed at the depth of
reference applicator. Associated statistical uncertainty with the simu-
R90 for each studied electron energy (for 10 MeV electron energy, a
lation results was less than 1% in all of the performed Monte Carlo
1 mm PLA slab was also used to exactly reach the R90 at this electron
calculations. More histories were followed is phase space calculations
energy). The collected charge by Advanced Markus ionization chamber
(DOSXYZ dosimetry) than for the generation of the phase space (over-
was measured via a UNIDOS E digital electrometer (PTW-Freiburg,
sampling) files until this desired statistical uncertainty was attained.
Germany). The PDD data for all electron energies were obtained inside
The 2D and 3D views of the simulated LIAC12 head in conjunction
the PLA bolus through the above-described procedure.
with the attached reference applicator are shown in Fig. 2.
The placement of Advanced Markus ionization chamber inside the
designed holder and the irradiation setup with 10 cm reference appli-
2.4. Measurements cator are shown in Fig. 3. It should be mentioned that a thick PLA slab
with 2 cm thickness plus 10 cm PMMA slabs (as shown in Fig. 3) were
In order to evaluate the efficacy of the constructed PLA based also placed below the ionization chamber dosimeter to fully satisfy the

3
S.H. Zoljalali Moghaddam, et al. Radiation Physics and Chemistry 174 (2020) 108952

Fig. 2. (A) 2D and (B) 3D views of simulated LIAC head along with reference applicator using BEAMnrc Monte Carlo code.

Table 3
Reported R90 values for different electron energies of LIAC
accelerator at the reference condition (Robatjazi et al.,
2018).
Electron energy (MeV) R90 (mm)

6 14
8 22
10 27
12 32

electron backscattering condition during the measurements. The

chamber voltage during the measurements was equal to 300 V. In ad-
dition, there was no distance between the phantom surface and end of
applicator during the measurements.
PDD measurements inside the water were performed by an MP3-XS
automatic water phantom (PTW-Freiburg, Germany). To this end, the
Advanced Markus ion chamber was located inside the phantom and
PDD data along the clinical axis of the reference applicator at different
electron energies were acquired by a TANDEM electrometer (Type
10011, PTW-Freiburg, Germany). Chamber movements inside the water
phantom were also remotely controlled by a TBA controller unit. All of
the measurements were performed according to the recommendations
of IAEA TRS-398 and AAPM TG-106 dosimetry protocols (Andreo et al.,
2006; Das et al., 2008).
One of the main limitations during the PDD measurement inside the
PLA bolus was the lack of PLA-to-air mass stopping power ratios to
convert the obtained percentage depth ionization (PDI) curves to per-
centage depth dose (PDD) curves. Therefore, a separate Monte Carlo
based calculation procedure was followed by means of SPRRZnrc Monte
Carlo code to determine the Spencer-Attix PLA-to-air mass stopping
power ratios at different measurement depths (Berger et al., 1975; Ding
et al., 1995; Rogers et al., 2010). The recommended formalism by
Seltzer and Berger is employed in this code to calculate the stopping
power ratios (Berger and Seltzer, 1964). The SPRRZnrc code can cal-
culate the stopping power ratios in the cylindrical geometry by con-
sidering the energy fluence spectra of the incident electrons to each
cylindrical region. As recommended by different dosimetry protocols
(Andreo et al., 2006; Almond et al., 1999; AAPM TG 21, 1983), the
lowest electron energy level, to consider its consequent secondary Fig. 3. The employed setup for PDD measurement inside the PLA material. As
electrons as a part of electron energy spectra, was set to 10 keV during shown in this Figure, some thick PMMA slabs have been put beneath the PLA to
the calculation of the stopping power ratios at different depths. satisfy the backscattering condition.
The stopping power ratios were calculated along the central axis of
the intraoperative electron beam at different energies and inside the

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S.H. Zoljalali Moghaddam, et al. Radiation Physics and Chemistry 174 (2020) 108952

cylindrical scoring cells with the dimensions of 5 mm (height) × 2 mm

(diameter) which were filled by the PLA material. Only the first scoring
cell (surface one with the dimensions of 1 mm (height) × 2 mm (dia-
meter)) was filled with the air in order to calculate the PLA-to-air
stopping power ratios. Due to a large number of the followed histories
(109 histories), the associated statistical uncertainty with the calculated
stopping power ratios was less than 0.1% at all of the studied energies.

3. Results and discussion

The comparison between the measured PDD curves inside the water
phantom and those obtained by BEAMnrc Monte Carlo code are pre-
sented in Fig. 4. All of the comparisons are performed for reference
applicator and at different intraoperative electron energies of 6, 8, 10
and 12 MeV.
As it can be seen from Fig. 4, there is a good agreement between the
results of Monte Carlo simulation and ionometric measured ones. the
results of gamma analysis for quantitative comparison between the
results also showed that the gamma index is less than 1 at all of the
evaluated depths (the dose difference (DD%) and distance to agreement
Fig. 4. Comparison between the measured and simulated PDDs at different
(DTA) in the calculations of the gamma index were considered as 2%
electron beam energies. All of the results are related to the 10 cm diameter
applicator (reference applicator).
and 2 mm, respectively). Therefore, the validity of the developed Monte
Carlo model of the LIAC head was confirmed.

Fig. 5. The simulated PDDs inside two PLA infill percentages of 60% and 100% and comparison of the obtained results with those of water at 6 and 8 MeV electron
energies.

5
S.H. Zoljalali Moghaddam, et al. Radiation Physics and Chemistry 174 (2020) 108952

Fig. 6. The simulated PDDs inside two PLA infill percentages of 60% and 100% and comparison of the obtained results with those of water at 10 and 12 MeV electron
energies.

Table 4 buildup region for 100% infill percentage of PLA have better ac-
Mean difference between two calculated PDD curves in water phantom and PLA cordance with the calculated PDDs at different electron energies inside
60%, PLA 100% phantom. the water.
Energy Mean PDD Mean PDD Mean gamma Mean gamma The mean difference between the calculated PDDs inside the PLA
(MeV) difference (%) difference (%) index (PLA- index (PLA- with two different infill percentages and those calculated inside the
(PLA-60%) (PLA-100%) 60%) 100%) water are reported in Table 4. The corresponding mean gamma index
values (2%/2 mm) are also presented in this Table.
6 1.2 0.9 0.3 0.3
8 1.4 0.4 0.7 0.2 The reported data in Table 4 also confirm that the 100% infill
10 0.5 0.8 0.5 0.5 percentage of PLA has a more desirable performance in reproducing the
12 2.5 0.2 1.2 0.1 obtained PDD curves inside the water at different intraoperative elec-
tron beam energies. As a result, the 100% infill percentage was selected
for construction of the PLA bolus by means of the 3D printing proce-
The results of PDD calculation at the buildup region of different dure. PLA boluses with low infill percentage have an air-involved mesh
intraoperative electron beam energies and inside the PLA bolus, with structure which causes a heterogeneous bolus formation. Furthermore,
two infill percentages of 60% and 100%, are shown in Fig. 5 and Fig. 6., due to the incorrect density approximation at the low values of infill
respectively. Considering the fact that the treatment planning proce- percentages, the constructed bolus cannot be considered as a homo-
dure and Monitor Unit (MU) calculation in IOERT are only based on the geneous substance. Therefore, the performance of PLA as an IOERT
obtained PDD data inside the water (Baghani et al., 2019c, 2019d), the bolus would be improved with increasing the infill percentage, due to
obtained PDD curves inside the PLA with two different infill percen- the increased homogeneity of 3D printed PLA material.
tages (60% and 100%) were compared with those of water to decide The calculated PLA-to-air stopping power ratios along the central
about the more proper infill percentage for bolus design and con- axis of the intraoperative electron beam at different energies and
struction. comparison with water-to-air ones are presented in Fig. 7.
As demonstrated by Figs. 5 and 6, the obtained PDD data at the

6
S.H. Zoljalali Moghaddam, et al.
Fig. 7. Calculated stopping power ratios for PLA bolus and water relative to air using SPRRZnrc Monte Carlo code at different electron energies of 6, 8, 10 and
12 MeV.
It should be mentioned that the extracted electron fluence spectra
(including energy, spatial and angular distribution) from BEAMnrc code
were imported to the SPRRZnrc code to obtain the corresponding PLA-
to-air stopping power ratios at different energies.
As it can be seen from Fig. 7, the obtained stopping power ratios
inside the PLA considerably differ from those of water. The maximum
difference between the PLA-to-air and water-to-air stopping power ratio
was about 5.42% which may be related to the different effective atomic
number, composition and electron density of PLA respect to water
which can change the electron fluence spectra in comparison with those
exist inside the water.
The measured PDD curves inside the constructed PLA bolus (with
100% infill percentage) at different electron energies and their com-
parison with those measured inside the water phantom are shown in
Fig. 8. The results of the performed gamma analysis for each electron
energy are also presented in Fig. 9. It should be mentioned that the
obtained data inside the PLA are only reported in buildup regions be-
cause the presence of radioprotection shield during the IOERT causes
falling the PDD to zero at depths behind the shielding disk.
As illustrated by Figs. 8 and 9, there is a very good agreement be-
tween the measured PDDs inside the PLA (100% infill percentage) and
water at different electron energies, so that the calculated gamma index
value (1%/1 mm) was less than 1 at almost all of the measurement
depths. Therefore, employing the designed buildup bolus upon the
7
Radiation Physics and Chemistry 174 (2020) 108952
target area doesn't change the intraoperative dose distribution respect
to water and follows the same trend which would be observed at the
presence of water.
Due to the closely matched dosimetric data to that of water, em-
ploying the PLA bolus upon the IOERT target area will not affect the
accuracy of the performed treatment plan. Therefore, in the presence of
PLA buildup bolus, the medical physicist can still refer to the measured
PDDs inside the water for treatment planning and PLA bolus does not
influence the characteristics of considered PDD (based on measurement
inside the water) for patient treatment planning. The presence of this
bolus merely increases the percentage dose level at the target surface,
because of the buildup effect of the over-laid bolus layer, and finally
increase the received dose by the surface which is one of the main
concerns and mandatory issues during the breast IOERT.
Due to the lower percentage dose level of surface respect to the
deeper parts of the target in the buildup region, the isodose prescription
should be decreased to fully cover all parts of target regions including
the surface. This subject can lead to the formation of hot points inside
the target, increased dose non-uniformities within the target volume
and increased number of required MUs to administer the prescribed
dose to the patient. The latter case can also increase both the workload
of IOERT machine and treatment team exposure which are not desirable
and should be kept as low as possible for each treatment. Therefore, the
presence of this PLA based buildup bolus, if necessary, not only
S.H. Zoljalali Moghaddam, et al.
Fig. 8. Comparison between the measured PDDs inside the constructed PLA bolus and water phantom at different electron energies of 6, 8, 10, and 12 MeV.
increases the surface dose, but also avoids such unfavorable issues
through increasing the isodose prescription level for treatment dose
delivery.
One of the main concerns during the employment of the PLA bolus
for IOERT is the type of sterilization process which should be applied
for this material to preserve the physical and chemical characteristics of
the bolus. Savaris et al. (2016) have evaluated the effect of different
types of sterilization methods including ethylene oxide, hydrogen per-
oxide plasma, saturated steam, electron beam radiation and gamma
radiation on the physical and morphological properties of PLA material.
The results of this study showed that the saturated steam method is not
appropriate for PLA sterilization, while other processes can be safely
applied for PLA sterilization without significant degradation of the PLA
structure.
The treatment centers which are equipped with this radiotherapy
technique, often use a sterile wet gauze as the buildup bolus.
Unfortunately, the thickness of this wet gauze may change over the
gauze area and can finally lead to the dose non-uniformity inside the
treatment area. Furthermore, the applicator pressure on the patient
surface can also compress the wet gauze and change its thickness as
well as agglomerate it after the connection of the accelerator head to
the patient during the docking procedure. On the other hand, em-
ploying a biocompatible, flexible and solid PLA bolus with a uniform
thickness can obviate all of these issues.
8
Radiation Physics and Chemistry 174 (2020) 108952
The role of PLA material as the bolus in external electron beam
radiotherapy has been also evaluated and discussed by Diamantopoulos
et al. (2018). Both experimental and Monte Carlo based plans were
followed to determine the depth scaling (cpl) and fluence scaling factors
(hpl) of this material in the megavoltage electron beam. The results of
this study support the performance PLA as a suitable bolus in external
electron radiotherapy regarding its very near cpl and hpl data to those
suggested by IAEA TRS- 398 protocol. The results of our study also
confirmed the desirable performance of this material as the bolus in
intraoperative radiotherapy. Therefore, the use of this material as
buildup bolus is recommended in any electron radiotherapy technique
either external or intraoperative treatment.
The comparison between the PMMA and PLA materials as the
buildup bolus has been also discussed by the mentioned study
(Diamantopoulos et al., 2018). A suggested by IAEA TRS-398 dosimetry
protocol (Andreo et al., 2006), the average depth scaling (cpl) and
fluence scaling factor (hpl) of employed bolus materials in electron
energies lower than 10 MeV should be about 0.946 and 1.054, re-
spectively. The performed analysis by Diamantopoulos et al. (2018)
showed that the values of these parameters for the PLA are equal to
0.948 and 1.059, while the PMMA has the values of 0.944 and 1.024 for
cpl and hpl, respectively. This study also confirmed the usability of PLA
material as an effective bolus and its nearer performance to the IAEA
recommendations respect to the PMMA material.
S.H. Zoljalali Moghaddam, et al.
Fig. 9. The results of gamma analysis (obtained gamma index values at different depths shown with solid circles) for comparison between the measured PDD curves
inside the water and PLA at different electron energies of 6, 8, 10, and 12 MeV.
4. Conclusion
A buildup bolus based on PLA material was designed and introduced
for employment in breast intraoperative electron radiotherapy (IOERT).
The appropriate infill percentage of introduced PLA bolus was de-
termined by Monte Carlo method. The performance of constructed
bolus was also evaluated through direct ionometric dosimetry inside a
PLA made bolus and comparing the obtained results with those mea-
sured inside the water. The obtained results showed that the developed
bolus has desirable performance characteristics and can be used to in-
crease the received dose by the surface during the breast IOERT. The
introduced bolus can be considered as a useful substitution for the wet
gauze which is often used as the buildup bolus during the intraoperative
radiotherapy.
CRediT authorship contribution statement
Seyed Hamid Zoljalali Moghaddam: Methodology, Validation,
Formal analysis, Data curation, Investigation, Writing - original draft,
Writing - review & editing. Hamid Reza Baghani: Conceptualization,
Methodology, Formal analysis, Investigation, Writing - original draft,
Writing - review & editing, Visualization, Project administration,
Supervision. Seyed Rabi Mahdavi: Conceptualization, Methodology,
9
Radiation Physics and Chemistry 174 (2020) 108952
Formal analysis, Resources, Validation, Visualization, Project adminis-
tration, Supervision.
Declaration of competing interest
We wish to confirm that there are neither conflicts of interest as-
sociated with this manuscript nor significant financial support for this
work that could have influenced its outcome. The manuscript has been
read and approved by all named authors.
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