Submission Packet 

You are required to submit this packet with each submission of your paper. You
will build on each draft and will also build on each submission packet so it will
represent the changes of your paper from start to finish. In this packet, you will
find: 
I. Statements 
II. Change Matrix 
III. AMA Formatting Checklists 
The instructions for each section are listed below. Copy and paste the statement
page, change matrix table and AMA formatting checklist table to the first page
of your draft submission. Remember that you should build on each submission.  
Page Break 

Statements 
Remember the problem, purpose and hypotheses statements that we worked so
hard on last semester? We will be using them again! They should be stated in
your paper (just as we worked on in your research proposal) but we are also
asking you to spell them out here as a reminder of the foundational basis for your
research.  
Purpose Statement: The purpose of this research study is to introduce a 3D milled rigid bolus
technique combined with VMAT treatment planning to evaluate the dosimetric efficacy in
delivering dose to the surface of the scalp. 
Problem Statement: Due to the anatomical shape of the cranium, adequate dose homogeneity
and full prescription dose delivery to the scalp still remains a dosimetric problem during scalp
irradiation.     
Hypotheses:  
H1: using a 3D milled rigid bolus with VMAT will increase surface dose homogeneity 
H10: using a 3D milled rigid bolus with VMAT will decrease surface dose homogeneity  
H2: using a 3D milled rigid bolus with VMAT will increase the percentage of planning target
volume (PTV) receiving prescription dose 
H20: using a 3D milled rigid bolus with VMAT will decrease the percentage of PTV receiving
prescription dose 
Page Break 

Change Matrix 
A change matrix is required with every milestone document submission. 
A detailed change matrix simplifies the review process and indicates to the instructors and advisors that
the author has demonstrated a clear and thorough response to reviewer comments.   
Reviewer comments are not intended as an exhaustive list. It is the Learner’s responsibility to correct
any additional errors that are not specifically noted by the reviewer and to address the requirements of
the capstone project.  All instances where changes have been made should be clearly noted.   
If, after discussion with the group, there are questions about a reviewer’s comments, it is the
responsibility of the group leader to reach out to the instructors and advisor via email for clarification.  
If, after discussion with the instructors, the author chooses not to make a requested change, the
author must provide a brief rationale, and describe how they addressed reviewer concerns. 
Failures to consider, address, and notate within the Change Matrix will result in the manuscript being
returned to the group without comment. 
Copy and paste the instructor’s comment from your draft into the matrix.  
You will continuously build on this change matrix so that any/all comments can be reviewed at any given
time in the projects progress.  
Title of Capstone:  Dosimetric Evaluation of Volumetric Modulated Arc Therapy (VMAT)
Treatment Planning Combined with 3D Milled Bolus for Patients Receiving Total and Partial
Scalp Irradiation: A Case Study 
 
Group: 8  

Reviewer’s recommendation   How addressed   Page numbers

where change
appears  
Example  Example  p.52 
A1. The author must clarify the variable H20   has been reworded to more clearly
constructs for hypotheses testing.    identify the two variables being
compared: the dependent variable which
is the ratio of (a) cash flows from
operating activities to (b) earnings from
continuing operations, compared when
the independent variable, fraud, is yes or
no. The two constructs that make up the
dependent variable are well known in
accounting and finance literature and are
not defined here. 
D1.There seems to be something I re-read the reference listed at number p. 11 
missing. I see the introduction of a 5 and evaluated the 3D printed bolus  
3D printed bolus and how that creation. I then listed the weakness of
improved homogeneity. But I don’t the printed bolus in the second
see the disadvantage or limitations paragraph. VMAT was addressed in
of that which would take us into the the first paragraph of the introduction
next paragraph of why your are and it was shown as being
researching 3D milled bolus with advantageous to that of 3D conformal
VMAT. There has to be something and IMRT.  
that tells us the difference between
printed and milled and also if
VMAT has not been looked at
already. You’ll have to expand a bit
before your last paragraph. 
D2.  A. This sentence should A. replaced with: Confounding A. P.12 
summarize all the points of your variables such as gravity, the  
intro on why/how the problem irregular and convex shape of the  
exists.   cranium, air gaps between scalp  
B.  I question word choice here. You surface and commercial bolus, and  
are suggesting that you have solved potential inconsistencies in 3D  
the problem already in this sentence printed boluses can negatively  
and are introducing the technique as impact the dose delivered to the B. P.12 
a good alternative but you scalp surface during scalp  
don’t actually know that yet.  irradiation.  C. P.12  
C. This should be stated in the B. Replaced with: implement the  
paragraph above when you’re use of   
discussing the potential benefits to C. Moved the sentence to desired D. p.13 
milled bolus.   paragraph   E. p. 13 
D. This is not an appropriate D. changed to 3D milled bolus   
abbreviation to use in place of milled E. Elaborated more on the F. p. 13 
3D bolus.   order/process   
E. Was the CT imported into the F. changed to :The phase I CT  
TPS first?  scan was then imported to create a  
F. This is not an appropriate intro 3D virtual bolus  
sentence. Is the entire paragraph using Varian™’s Eclipse® Version G. p. 13 
about making the external contour?   13.7 or 15.6 treatment planning  
G. These sentences are bulky. I think system (TPS)   
you can describe the process in one G. sentence structure was redone. H. p. 19 
sentence. “To develop the bolus Elaborated on the process of I. p. 15 
outline, a 2 cm rind was creating the bolus vs the rid  
created around the cranium.” Or structure itself.   
something similar. Simply explain H. Figure added    
the process.   I. Explained how the CTV J. p. 15 
  contour was created/evaluated, and  
H. I think a figure here would how the PTV was created off of the K. p. 15 
be really useful.   CTV   
I. ?? What was desired? How did J. moved to page 17 and created  
they decide?  subtitle: Treatment Delivery   
J. I would move this until after the   L. p. 16 
OAR objectives but before results. It K. Sentence was deleted to avoid  
might even need a confliction with prior one.   M. p. 19 
separate heading but we’ll see how it  
all comes together with the results.   
K. I don’t know what you mean by L. This information is known by
this? The previous sentence stated the audience, and therefor omitted
that the CBCT was used for after revision 
alignment to target and bolus.   M. This table will more than likely
L. Simplify. The prescription for be omitted, and the source of the
each patient was given to the constraints used will be listed
medical dosimetrist and varied directly in the text. Currently, the
between xyz for the high risk area table remains to ensure the
and xyz for the lower risk area.  information is retained until further
M. This table will need to be revision. 
recreated. It’s not of good quality
and max should not be used. You
can use < or > symbols 
 
 
  
 
 
 
 
 
 
 
 
 
 a. I moved where 3D milled is at in this  a. Completed this change according to  a. p. 11
sentence. If you end with 3d milled instruction
bolus, then you don’t have to insert the
phrase ‘now referred to as 3D milled
bolus. It’s sort of understandable that
you will refer to the bolus as 3D milled
bolus.

b. I don’t understand this. b. removed “of oblique” and simply put b. p.11
thin areas
c. Do you really mean snuggle? Or snug c. Replaced with conforming c. p. 12
fitting? Perhaps use conform, close-fitting,
secure, or something like that.

     

     

     
 
AMA Referencing Quick Guide Checklist 
Correctly using AMA formatting is one of the few aspects in the Capstone project that you have
complete control of whether it is your first outline submission or the final draft. Use this AMA quick
guide checklist to avoid common AMA formatting mistakes and receive the greatest number of points
possible. Not everyone has the ability to be an exceptional scholarly writer and researcher, however,
everyone has the capability of using AMA formatting correctly. Review this guide for EVERY submission
(discussion post, outline, draft) in the research courses and ask yourself the following questions: 
 
Task  Submission Submission Submission Submission Submission Submission Submission
Date: Date:  Date:  Date:  Date:  Date:  Date: 
6/12/20  7/2/20  7/26/20  8/8/20

Manuscript 
Written in past tense?  ☒  ☒  ☒  x ☐  ☐  ☐ 
             
Written in size 12, Times ☒  ☒  ☒  x  ☐  ☐  ☐ 
New Roman font             
Paragraphs include at least 3 ☒  ☒  ☒  x  ☐  ☐  ☐ 
sentences               
Page numbers?  ☒ 
  I am not
**The default font for page sure how to
numbers is Calibri, size 11 make it
even after you have sticky, I
changed the font in your change it
☒  ☒  x  ☐  ☐  ☐ 
paper so make sure to but cant tell
           
check  if it has
been
applied
when
closing the
header 
Spell out abbreviation at
first use if not recognized by
AMA 
 
***Remember that you ☒  ☒  ☒  x  ☐  ☐  ☐ 
may add/subtract content              
with each draft so
something that once spelled
out might be removed and
need to spelled out again 
Spell out numbers and ☒  ☒  ☒  x  ☐  ☐  ☐ 
abbreviations that begin a              
sentence?   
 
**If an abbreviation must be
spelled out to begin a
sentence, do not include the
abbreviation in parentheses
after words unless this is the
first use. 
Numeric values when
☒  ☒  ☒  x  ☐  ☐  ☐ 
referring to numbers in
             
sentence (“3”, not “three”) 
Reference superscripts after
☒  ☒  ☒  x  ☐  ☐  ☐ 
each sentence I used
             
a reference? 
OAR is properly defined
as organS at risk.  
 
**This is a common mistake, ☒  ☒  ☒  x  ☐  ☐  ☐ 
even in journal publications.              
By saying OARs, you are
implying organs at risks
which doesn’t make sense 
If I directly cited an author,
did I immediately include
☒  ☒  ☒  x  ☐  ☐  ☐ 
the reference superscript
             
following the author’s
name? 
Tables and figures are
referenced in-text directly ☐  ☒  ☒  x  ☐  ☐  ☐ 
following the sentence (….              
(Figure 1).  
All terms must be spelled
out in the abstract and
manuscript at first use 
 
☒  ☒  ☒  x  ☐  ☐  ☐ 
**So if you refer to and spell
             
out VMAT in the abstract,
you must also define the
term again in the
manuscript 
Scholarly writing is
appropriate 
 
**Do not use terms such as ☒  ☒  ☒  x  ☐  ☐  ☐ 
max, cord,              
rad onc, simmed etc. Spell
out these terms and avoid
slang 
All reference of our
profession should be written
as “medical dosimetrist” not
☒  ☒  ☒  x  ☐  ☐  ☐ 
just “dosimetrist.” 
             
 
**Remember that there are
other types of dosimetrists 
Is my paper formatted ☒  ☒  ☒  x  ☐  ☐  ☐ 
according the instructions?
Case study vs. Research    
Paper 

Reference Page 
Page break before this
☒  ☒  ☒  X ☐  ☐  ☐ 
section? 
Capitalize the first letter
of the first word in the ☒  ☒  ☒  x  ☐  ☐  ☐ 
title only 
Abbreviate and italicize
☒  ☒  ☒  x  ☐  ☐  ☐ 
the journal? 
Year, volume, issue and
page number
written without any
spaces?  
 
**If you didn’t find one
☒  ☒  ☒  x  ☐  ☐  ☐ 
listed, consider
completing another
literature search review.
If you cannot find one,
reach out to instructor
for help 
Doi? 
 
**Remember
that most publications
have doi numbers now
☒  ☒  ☒  x  ☐  ☐  ☐ 
so if you do not locate
one on the original
article, complete
another literature search
to find it. 
Format dois like
this: http://doi.org...  
  ☐ 
☐  ☒  ☒  x  ☐  ☐ 
**Remember this  
has changed from last
semester 
Listed in chronological
order as they are ☒  ☒  ☒  x  ☐  ☐  ☐ 
referenced in text 
Figures and Tables 
Page break before each
☐  ☒  ☒  x  ☐  ☐  ☐ 
section? 
Each heading is bolded ☐  ☒  ☒  x  ☐  ☐  ☐ 
and centered for each
section 
If 2 figures are related,
they are to be labeled as ☐  ☐  ☒  x  ☐  ☐  ☐ 
A and B. 
Captions are written in
complete sentences and
☐  ☐  ☒  x  ☐  ☐  ☐ 
single spaced starting
with “Figure 1”  
Figure captions
☐  ☐  ☒  x  ☐  ☐  ☐ 
appear after the figure 
Table captions
☐  ☒  ☒    ☐  ☐  ☐ 
appear before the figure 
All patient identifying
information is blocked
☐  ☒  ☒  x  ☐  ☐  ☐ 
and fused with the
original image 
All table axis, labels and
legends are in Times
☐  ☒  ☒  x  ☐  ☐  ☐ 
New Roman, size 12
font 
Any DVHs include
structure labels directly ☐  ☐  ☐    ☐  ☐  ☐ 
on the DVH 
Vertical lines are
☐  ☒  ☒    ☐  ☐  ☐ 
removed from tables 
Single line spacing used
for figure and table ☐  ☒  ☒  x  ☐  ☐  ☐ 
descriptions 
 
 
 
 
 
 
 
 
 
 Dosimetric Evaluation of Volumetric Modulated Arc Therapy (VMAT) Treatment
Planning Combined with 3D Milled Bolus for Patients Receiving Total and Partial Scalp
Irradiation: A Case Study 

Introduction:  
Superficial scalp lesions are rarely seen in radiation oncology, but when encountered,
they are challenging to plan. Historically, these superficial scalp lesions were treated using a
variety of approaches ranging from electron therapy, photon therapy, to a dual energy electron-
photon matched field therapy; however, these methods of treatment were labor intensive and
introduced a lot of inconsistencies in daily setup and deliverability. Fortunately, current
advancements in clinical oncology have led to new methods of treatment for superficial scalp
lesions. Specifically, advancements such as the use of Intensity Modulated Radiation Therapy
(IMRT) and Volumetric Modulated Arc Therapy (VMAT) have helped radiation therapy become
a viable treatment option for those who have scalp lesions. Intensity Modulated Radiation
Therapy and VMAT have shown promise in delivering effective radiation treatments to total
scalp patients for those who have squamous cell carcinoma, melanoma, mycosis fungoides,
lymphoma of the scalp, or an angiosarcoma diagnosis.1 Although IMRT and VMAT techniques
are capable of being used as a treatment method, another study completed by Kai et
al2 introduced the difficulty still associated with getting uniform dose to the target while sparing
organs at risk (OAR) such as the brain and optical structures. Such difficulties in achieving a
uniform dose distribution is due in part to the natural convex shape of the cranium.3 To combat
this issue, traditional bolus methods, such as wet wash clothes or Superflab, have been used to
shift the isodose distribution towards the surface of the scalp.  
Over the past several years, facilities have been experimenting with different bolus
methods coupled with the use of IMRT or VMAT technologies to achieve a more desirable and
homogenous dose distribution for total scalp irradiation, specifically to the surface of the
skin.1 One effective way to increase the deposition of superficial dose is to decrease the air gap
between the bolus and the skin surface.4 However, decreasing the air gap in the clinical setting is
not always possible using a commercial flat bolus on scalp patients due to confounding
variables such as gravity with a supine setup, the shape of the skull, and irregular surface
topography such as post-operative surface changes, or contouring around the brow and auricular
area.5 Instead, facilities have developed a 3D printed bolus specifically for use on the
scalp.6,7 Rakici et al8 demonstrated that the dose distribution, homogeneity, and conformity index
improved by using a 3D printed bolus with VMAT or IMRT.8 An improvement in plan
homogeneity and conformity helps deliver adequate dose to the tumor  and target volumes, while
also reducing low dose continuation into underlying OAR much like that of the brain and critical
optic structures. Although 3D printed boluses have shown to be beneficial in scalp treatments,
there is also a degree of uncertainty associated with their composition. Due to the fill space, layer
resolution, print strength, and print pattern limitations of the 3D printer, air cavities within the
bolus can become a concern.5 Another concern with 3D printed bolus is that the interior surface
may not be rendered completely smooth in production. Decreased smoothness and conformity
can affect dose homogeneity as well as patient comfort. Lastly, the 3D printed bolus has various
densities and rigidity principles based on the type of filament used to print the bolus. On the
contrary, a 3D milled bolus can diminish the probability and concerns associated with a 3D
printed bolus composition. The 3D milled bolus method is unique in that it consists of generating
a 1 cm uniform thickness bolus that encompasses the entire treatment area. Likewise, the bolus is
milled out of a uniform-density block rather than printed from a filament.   
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 research study is to implement the use of a 3D milled rigid bolus technique
combined with VMAT treatment planning and evaluate the dosimetric efficacy in delivering
dose to the surface of the scalp. The researchers hypothesize that using a 3D milled rigid bolus
with VMAT (H1A) will increase surface dose homogeneity as well as (H2A ) increase the
percentage of planning target volume (PTV) receiving prescription dose. 
 
Case Description 
Patient Selection 
Patients for this study were selected in a retrospective manner and the 8-patient
population consisted of both male and female genders. Each patient had a cutaneous scalp
lesion consistent with an angiosarcoma or squamous cell carcinoma cytology. Each
individual was treated post-operatively to the tumor bed as well as to associated intermediate risk
areas of the scalp. All patients were treated using a 6 MV VMAT technique and a patient specific
1 cm uniform thickness rigid 3D milled bolus.  

Simulation Procedure and Bolus Creation 

The treatment simulation was conducted in 2 phases. Phase 1 of the treatment simulation
was performed at the time of patient consult to generate and build the 3D milled bolus. During
this CT scan, each patient was simulated in the supine position, head resting on a clear plastic
Silverman head rest, arms on their chest holding a ring, and a knee cushion. During this process,
radiopaque wires were placed by the attending radiation oncologist to delineate the high risk,
post-operative, and intermediate risk areas of the scalp to be included in target volumes. To limit
radiation exposure, the scan length was reduced to include only the head and wired areas with
enough margin to build a bolus structure in the treatment planning system (TPS).  
 The phase 1 CT scan was then imported to create a 3D virtual bolus using Varian Eclipse
Version 13.7 or 15.6 treatment planning system (TPS). After importation, the planning medical
dosimetrist then reviewed and delineated the external body contour that was automatically
created by the TPS to ensure that the patient’s external surface was contoured accurately. With
special emphasis required to render bolus from a surface structure, it was often necessary during
the editing process to manually segment the surface of the brow, the lobes of the ear, and any
post-operative surface irregularities during this process. The radiopaque wires were converted to
high resolution structures and delineated to both the high risk and intermediate risk areas. Using
the outermost wire, a contour was rendered expanding outward 2 cm uniformly to give bolus
margin from the field edge. Then, a uniform 1 cm rind structure was generated by expanding the
external contour outward. Next, the area of overlap between the 1 cm rind and 2 cm field
expansion was converted into a single representation of bolus. The 3D virtual bolus
representation was carefully reviewed and edited to remove any thin areas, especially around the
post-auricular surface and brow. Lastly, 2 indexing points, or knobs, were added manually to the
bolus structure on the anterior aspect of the contour to later index with thermoplastic mask
during phase 2. This structure was then sent to a third-party vendor in digital imaging
and communication in medicine (DICOM) format to be milled. The proprietary wax compound
making up the 3D milled bolus had an electron density of 0.92 g/cm3.  
 Phase 2 of the treatment simulation process occurred once the 3D milled bolus was
returned to the radiation oncology department and was inspected. In this phase, each patient was
simulated in the supine position, with the 3D milled bolus in place on the patient’s scalp, on top
of a Qfix Q2 Silverman head rest. Additionally, a MOLDCARE custom headrest was utilized to
conform to the posterior aspect of the bolus, holding it in place. A thermoplastic mask was
formed over the patient’s head and shoulders, with emphasis placed on conforming it around the
mandibular arch, brow, nose, and bolus during the process. Likewise, the index knobs on the
bolus were carefully contoured while forming the mask to ensure setup reproducibility. The
patient’s arms were placed at the sides, hands gripping indexed alpha-numeric handles, with an
indexed knee sponge (Figure 1). Lastly, a rigid fusion was performed between the phase 1 and
phase 2 simulations in the TPS, allowing for the radiopaque wires to delineate the high-risk
volume on the planning CT. 

Target Delineation                
The target delineation and treatment planning process were completed using Varian
Eclipse Version 13.7 or 15.6 TPS. The high-risk clinical target volume (CTV High) was
contoured by the physician on the CT data set delineated by the radiopaque wires. The high-risk
PTV (PTV High) was created by expanding the CTV High by 3 mm uniformly in all directions,
and then cropping to the skin surface. For the intermediate-risk CTV (CTV Int), the contours
were delineated by the attending physician and included the post-operative bed, the high-risk
area, as well as associated skin involvement to the scalp. The intermediate-risk PTV (PTV
Int) was generated by expanding the CTV Int by 3 mm in all directions, and then cropping to the
skin surface. After the targets were created, the planning medical dosimetrist was responsible for
contouring the organs at risk (OAR) following department guidelines, which refer to both
Radiation Therapy Oncology Group (RTOG) and European Organization for Research and
Treatment of Cancer (EORTC) 1709 contouring atlases.8 For this study, the OAR evaluated
dosimetrically included the normal brain, brain stem, optic lens, optic nerve, and optic chiasm, as
well as associated planning risk volumes (PRV).   
Treatment Planning 
All patients were treated using a 6 MV, VMAT, simultaneously integrated boost (SIB)
technique. Depending on the stage and diagnosis, the total dose between patients varied. A total
dose between 6000 cGy to 6600 cGy was delivered to the PTVHigh, and a total dose between
5400 cGy to 5940 cGy was delivered to the PTVInt over a course of 30 to 33 fractions. Every plan
was normalized so that dose to 95% of the PTV volumetrically (D95%) received 100% of the
prescription dose. 
For this treatment technique, 3 to 4 VMAT arcs were used as a beam arrangement based
on the size, extent, and location of the scalp target area. If the PTV was symmetrically placed
around the scalp, such as in total scalp irradiation, full 360 degree co-planar arcs were used. In
cases with unilateral and partial scalp targets, partial arcs with non-coplanar beams were
used when applicable. During beam setup, collimator jaws were minimized and locked to reduce
leakage when possible. Likewise, collimator rotations were independently placed for each patient
to promote sparing of midline OAR with multi-leaf collimators (MLC), with some fields split
into left, right, or superior fields using jaw locking. To create flash within the 3D milled bolus,
aiding in patient setup, a planning PTV was created prior to optimization. The planning PTV
consisted of an extension of the physician delineated PTV by 3mm outside of the surface
contour, extending it into the 3D milled bolus, which assisted in delivering dose to the skin
surface. Iterative 1 cm thick ring structures were created from the PTV High. Dose maximum
objectives were placed on the rings to carve out low dose and spare midline OAR, as well as
normal brain. Planning objectives used to limit and evaluate dose to OAR were created by the
physician's group from the Quantitative Analyses of Normal Tissue Effects in the Clinic
(QUANTEC) and the RTOG recommendations and findings.  

Treatment Delivery 
Before treatment commenced, the patients were imaged using cone beam computed
tomography (CBCT). The CBCT was then superimposed over the planning CT scan to ensure
3D milled bolus placement, the skulls position within the 3D milled bolus, and to verify the
target’s position. To help combat variations in the daily setup, these patients were only treated on
machines capable of producing 6 degrees of freedom (6 DOF) couch corrections. 
Results 
To determine if the 3D milled bolus aided in the achievability of
a more homogenous dose distribution to the surface of the scalp, the maximum dose D2% was
evaluated; in which, the D2% is the dose received by 2% of the PTV volume. This was completed
by examining each patients dose volume histogram (DVH) created by the TPS. Since
the PTVHigh received a higher dose than the PTVInt, the D2% was not evaluated for the PTVInt. For
the 8-patient population, the D2% average was found to be 108.2% of the prescription dose when
normalized so that dose to 95% of the PTV volumetrically (D95%) received 100% of the
prescription dose, with a 0.9 standard deviation. Therefore, it was concluded that the 3D milled
bolus aided in achieving a more homogenous dose distribution to the surface of the
scalp while also confining the acceptable single point maximum hotspot within the PTVHigh and
not the OAR within proximity of the PTV for 7 out of the 8-patients (Figure 2). 
To examine the effect that the 3D milled bolus had on the dose delivered to the PTV, the
minimum dose D98% was evaluated using the TPS DVH; in which, the D98% is the dose received by
98% of the PTV volume. Both the PTVHigh and the PTVInt volumes were evaluated by calculating
the average D98% of each volume for the 8-patient population. The PTVHigh D98% average was 98.3%
of the prescription dose when normalized so that dose to 95% of the PTV volumetrically (D95%)
received 100% of the prescription dose, with a 1.2 standard deviation. For the PTVInt D98%, the
average was 98.0% with a 1.0 standard deviation. Therefore, it was concluded that the 3D milled
bolus achieved adequate dose buildup and delivery to the superficial scalp PTVs (Figure 3).  

Conclusion 
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 research study was to implement the use of a 3D milled rigid bolus technique
combined with VMAT treatment planning and evaluate the dosimetric efficacy in delivering
dose to the surface of the scalp. Upon investigation, it was found that the 3D milled bolus in
combination with VMAT treatment planning technique delivered, on average, 98.3% of the
prescription dose to 95% of the PTVHigh , and an average of 98% of the prescription dose to
the PTVInt when normalized so that dose to 95% of the PTV volumetrically (D95%) received 100%
of the prescription dose. Their standard deviations were found to be 1.2 and 1.0 respectively. In
addition, the effect that the 3D milled bolus had on the plans isodose distribution and
homogeneity efficacy was evaluated by examining the maximum dose D2% and its location. The
D2% average was found to be 108.2% of the prescription dose when normalized so that dose to
95% of the PTV volumetrically (D95%) received 100% of the prescription dose, with a standard
deviation of 0.9. Furthermore, the D2% was confined to the PTVHigh for 7 out of 8-patients, which
was deemed acceptable by the attending physician, and all 8 plans were approved to be
used for clinical treatment. 
The researchers hypothesized that using the 3D milled rigid bolus with VMAT (H1A)
would increase surface dose homogeneity as well as (H2A) increase the percentage of planning
target volume (PTV) receiving prescription dose. Upon reviewing the results listed in the
previous section, it has been concluded that there is significant evidence to uphold the proposed
hypotheses and to reject the null hypothesis (H10) that using a 3D milled rigid bolus with VMAT
will decrease surface dose homogeneity, and null hypothesis (H20) that using a 3D milled rigid
bolus with VMAT will decrease the percentage of PTV receiving prescription dose for all 8-
patients enrolled in the study. Thus, patient specific 3D milled rigid bolus shows promise as a
viable bolus option for treatment of superficial scalp lesions coupled with VMAT treatment
planning.  
After initial analysis of the treatment plans, the researchers found that dose delivered to
underlying and surrounding OAR was dependent upon two variables. The first being the total
size of the PTV (PTVHigh + PTVInt = PTVTotal) in cm3. As the PTVTotal volume increased, the dose
received by the OAR increased too. Secondly, the priorities placed on the iterative rings during
optimization impacted the dose delivered to the OAR. It was found that increasing the priority on
the rings closest to the PTV decreased dose to underlying and midline OAR.  
Although the researches attempted to negate as many limitations as possible, a few still
apply. Due to the rarity of superficial scalp lesions, the number of participants enrolled in the
case study was limited to only 8-patients once the original 15-patient sample size was evaluated
per the inclusion criteria. A larger sample size would be desirable to be able to disseminate
findings across multiple institutions.  Another limitation to this study was the number of arcs
used for each patient case. Although the planning approach was as similar as possible, the
number of arcs to be used was based on the medical dosimetrist's preference. Instead, a tool like
the arc geometry tool, found in the TPS used, could have been implemented prior to optimization
to increase consistency between plans. These limitations warrant future research on the topic.
However, for this single institution case study, patient specific 3D milled bolus was evaluated
and proven to be a viable bolusing option for superficial scalp lesions.  
 
 

 
 
  
 
 
 References 
1. Ostheimer C, Hübsch P, Janich M, Gerlach R, Vordermark D. Dosimetric comparison of
intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) in
total scalp irradiation: a single institutional experience. Radiat Oncol J. 2016;34(4):313–321.
http://doi.org/10.3857/roj.2016.01935 
2. Kai Y, Toya R, Saito T, et al. Plan quality and delivery time comparisons between
volumetric modulated arc therapy and intensity modulated radiation therapy for scalp
angiosarcoma: a planning study. J Med Radiat Sci. 2018;65(1):39-47.
http://doi.org/10.1002/jmrs.239 
3. Mail N, Al-Ghamdi SM, Chantel C, Sedhu F, Rana A, Saoudi A. Customized double-
shell immobilization device combined with vmat radiation treatment of basosquamous cell
carcinoma of the scalp. J Appl Clin Med Phys. 2019;20(2):84-93.
http://doi.org/10.1002/acm2.12536 
4. Kong Y, Yan T, Sun Y, et al. A dosimetric study on the use of 3D-printed customized
boluses in photon therapy: A hydrogel and silica gel study. J Appl Clin Med Phys.
2019;20(1):348–355. http://doi.org/10.1002/acm2.12489 
5. Fujimoto K, Shiinoki T, Yuasa Y, Hanazawa H, Shibuya K. Efficacy of patient-specific
bolus created using three-dimensional printing technique in photon radiotherapy. Phys
Med. 2017;38:1-9. http://doi.org/10.1016j.ejmp.2017.04.023 
6. Baltz GC, Chi PM, Wong PF, et al. Development and validation of a 3D-printed bolus
cap for total scalp irradiation. J Appl Clin Med Phys. 2019;20(3):89–96.
http://doi.org/10.1002/acm2.12552 
7. Rakici SY, ÇINAR Y, EREN M. Total scalp irradiation: the comparison of five different
plans using volumetric modulated arc therapy- simultaneous integrated boost (VMAT-SIB)
technique. Turk J Oncol. 2017;32(3):106-115. http://doi.org/10.5505/tjo.2017.1609 
8. Clementel E, Verschuere T, Nuyens S, Corning C. Intergroup Study EORTC-1709-BTG.
Belgium: EORTC; 2020. 
 Figures 

 
Figure 1. Typical patient treatment position at the time of CT simulation.  
 

 
Figure 2. Sagittal image illustrating the homogenous dose distribution covering the superficial
scalp lesion while using the 3D milled bolus. 
 

 
Figure 3. Axial image illustrating the yellow 100% isodose distribution and the green 95%
isodose distribution covering the PTV outlined in red.