Tang et al.

Radiation Oncology (2023) 18:23 Radiation Oncology

https://doi.org/10.1186/s13014-023-02217-4

RESEARCH Open Access

Dosimetric comparison of two dose

expansion methods in intensity modulated
radiotherapy for breast cancer
Ran Tang1,2, Aimin Li1,2, Yingjing Li1,2, Guanhua Deng3, Yufeng Wang1,2, Qing Xiao1,2, Luosheng Zhang1,2 and
Yue Luo1,2*

Abstract
Background To explore the dosimetric difference between IMRT-VB plan based on the establishment of external
expansion structure and virtual bolus (VB) and IMRT-SF based on the skin flash (SF) tool of the Eclipse treatment plan-
ning system in postoperative chest wall target intensity modulation radiotherapy plan of breast cancer.
Methods Twenty patients with breast cancer were randomly selected as subjects to develop IMRT-VB plan based
on virtual bolus and IMRT-SF plan based on skin flash tool of Eclipse treatment planning system. The planning target
volume, monitor unit (MU) of every single treatment and the dosimetric parameters of organ at risk (OARs) were
recorded. Paired t-test was used for normal distribution data while nonparametric paired Wilcoxon rank sum test was
used for non-normal distribution data.
Results Both IMRT-VB and IMRT-SF plan can expand outward to the chest wall skin and meet the dose requirements
of clinical prescription. The conformal index, the homogeneity index, ­D2%, ­D98% and D
­ 50% were significantly better in
IMRT-SF plan than those in IMRT-VB plan (P < 0.05). The average MU of the IMRT-SF plan was much higher than that of
the IMRT-VB plan (866.0 ± 68.1 MU vs. 760.9 ± 50.4 MU, P < 0.05). In terms of organ at risk protection, IMRT-SF plan had
more advantages in the protection of ipsilateral lung and spinal cord than IMRT-VB plan (P < 0.05).
Conclusion Our study indicated that IMRT-SF plan displayed clinical application superiority compared to IMRT-VB
plan, and the operation steps of which are simpler and faster. Besides, IMRT-SF plan took advantages in achieve effec-
tive external expansion of skin dose intensity and OARs protection.
Keywords Breast cancer, Intensity modulated radiotherapy, Dose intensity expansion, Chest wall

Background
Since the low-density lung tissue was in the irradiation
area, the homogeneity index (HI) of traditional three-
dimensional conformal radiotherapy is as high as 20% in
the radiotherapy of breast cancer patients [1, 2]. Inten-
*Correspondence:
Yue Luo sity modulated radiotherapy (IMRT) has been widely
[email protected] used in breast cancer radiotherapy recently. Compared
1
Integrated Hospital of Traditional Chinese Medicine, Southern Medical with the traditional three-dimensional conformal radio-
University, No.13 Shiliugang Road, Guangzhou 510315, Guangdong,
China therapy, IMRT had obvious superiority in the uniform-
2
Cancer Center, Southern Medical University, Guangzhou 510315, China ity and conformal degree of the target volume, as well
3
Guangdong 999 Brain Hospital, Guangzhou 510510, China as the protection of organs at risk. However, the target

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Tang et al. Radiation Oncology (2023) 18:23 Page 2 of 7

volume of the chest wall extends beyond the skin due thickness and slice spacing of 0.5 cm and resolution of
to the movement of organs such as breathing and heart- 512 × 512.
beat [3, 4]. The existing radiotherapy planning system The radiologist delineated the clinical target volume
does not calculate the dose distribution outside the outer (CTV) of the chest wall according to the ICRU83 report
contour (that is, the skin), which was defaulted as zero- and White J’s research [7, 8]. The planning target vol-
dose area. Although previous studies have reported two ume (PTV) expanded 5 mm on the basis of CTV, and the
kinds of dose intensity expansion methods [5, 6], one is inner and posterior boundary was not allowed to extend
IMRT-VB plan based on virtual bolus (VB), the other is to the lung [9]. The anterior boundary retracted in the
IMRT-SF based on the skin flash (SF) tool of the Eclipse subcutaneous 3 mm to form a structure named PTV_eval
treatment planning system, there were few reports on [10]. This PTV-eval is limited anteriorly to exclude the
the application of these two dose expansion methods in part that extends outside the body/patient and the first
postoperative chest wall IMRT planning of breast cancer. 3 mm of tissue under the skin in order to remove some
Here, by employing two different expansion methods in of the buildup region for the DVH analysis. At the same
20 patients with left breast cancer, we found that both time, heart, left lung, right lung, spinal cord and other
IMRT-VB and IMRT-SF plan can expand outward to the organs at risk should be delineated. All the target areas
chest wall skin and meet the dose requirements of clinical and organs at risk were sketched by the same radiologist,
prescription. The conformal index (CI), the homogeneity and the prescription dose of PTV was 50 Gy/25F.
index (HI), D­ 2%, ­D98% and ­D50% were significantly better
in IMRT-SF plan than those in IMRT-VB plan (P < 0.05). Treatment planning
The average MU of the IMRT-SF plan was much higher The Eclipse13.6 planning system was used to estab-
than that of the IMRT-VB plan (866.0 ± 68.1 MU vs. lish the IMRT-VB plan based on the establishment of
760.9 ± 50.4 MU, P < 0.05). In terms of organ at risk pro- external expansion structure and virtual bolus (VB),
tection, IMRT-SF plan had more advantages in the pro- and the IMRT-SF plan based on the skin flash (SF) tool
tection of ipsilateral lung and spinal cord than IMRT-VB of the Eclipse treatment planning system. The accelera-
plan (P < 0.05). Taken together, our study indicated that tor is Varian Clinic X, 6MV energy X-ray, the dose rate
IMRT-SF plan displayed clinical application superiority is 400MU/min, and the dose is calculated by analyti-
compared to IMRT-VB plan, and the operation steps of cal anisotropic algorithm (AAA), along with a grid size
which are simpler and faster. Besides, IMRT-SF plan took of 0.25 cm used for dose distribution computation. The
advantages in achieve effective external expansion of skin intensity modulation plan of 8 fields was selected in
dose intensity and OARs protection. both groups, and the field angle was based on a pair of
tangent fields of breast target. In addition, 3 pairs of aux-
Methods iliary tangent fields were added within the tangent field
Human samples at an interval of 5–10° to form an intensity modulation
Participant were a total of 20 patients with left breast plan of 8 fields. To better protect the normal tissue from
cancer (pT3-4N0M0) who received postoperative radio- exposure, the fixed jaw technique was used in the opti-
therapy in the Radiotherapy Center of Integrated Hospi- mization of the plan [11], the field arrangement was set
tal of Traditional Chinese Medicine at Southern Medical as previous reported [12]. Schematic diagram of IMRT-
University during August 2020 to December 2021. All VB and IMRT-SF plan designed for patients was shown
patients were female, aged from 35 to 62 years old, with in Fig. 1.
an average age of 50.40 ± 9.59 years old. IMRT-VB plan: Firstly, a 1.0 cm outer contour exten-
sion bolus was added to the breast part of the Body, and
the CT value of the outer contour extension area was
CT simulation and target delineation specified as 0HU. A new outer contour (“Body + bolus”)
All patients were in supine position, with upper limbs was generated by Boolean (union) operation between the
abduction and arms crossed in front of forehead. The original outer contour Body and the 1 cm virtual bolus.
negative pressure vacuum pad was used for body posi- Then, a “PTV + 0.5” structure was generated by putting
tion fixation. Patients were asked to maintain a steady the PTV 0.5 cm outward toward the thorax. The angle
breathing state during CT scanning. The upper boundary layout of the radiation field was completed according to
of CT scanning is at the level of cricothyroid membrane, the above field layout principles. At the same time, fixed
the lower boundary is 5 cm below the fold of the lower jaw techniques were used, and PTV and “PTV + 0.5”
edge of the breast with 0.5 cm scanning thickness. Philips structures were simultaneously used as the target
Brilliance CT Big Bore was used to perform conventional area optimization targets for flux optimization. After
CT simulation positioning scanning, with scanning slice the flux optimization was completed and the clinical
Tang et al. Radiation Oncology (2023) 18:23 Page 3 of 7

Fig. 1 Schematic diagram of IMRT-VB and IMRT-SF plan designed for patients

requirements were met, the virtual bolus was removed index (HI). The calculation formulas of CI and HI were as
and the outer contour was reset to the original outer con- follows:
tour Body. The optimized radiation field flux was main-
2
Vt,ref
tained for dose calculation. Therefore, the IMRT-VB plan (1)
CI =
for dose intensity expansion was obtained. Vt × Vref
IMRT-SF Plan: The ‘Skin flash’ tool was a brush tool
that extends the dose in the form of dose intensity pro- D2% − D98%
jected at the inner edge of the field beyond the skin in the HI = (2)
D50%
Beam Eyes View (BEV). The angle distribution and fixed
jaw techniques of the radiation field were consistent with wherein, Vt,ref means the volume covered by the prescrip-
the IMRT-VB plan, and the PTV structure was taken as tion dose, Vt means the target volume, Vref means the vol-
the target area optimization targets. After the flux opti- ume covered by the prescription dose in the target area,
mization was completed and the clinical requirements ­D2%, ­D98%, ­D50% represent the radiation dose received by
were met, the ‘Skin flash’ tool in the Eclipse13.6 planning 2%, 98% and 50% of the volume of the target, respectively.
system was used to expand the skin flux of 0.5 cm in the The closer the CI value is to 1, the better the dose suit-
chest wall target area of all the fields and then the dose ability of the target area is; the closer the HI value is to
distribution was calculated, and then the IMRT-SF plan 0, the more uniform the dose in the target area is. The
was obtained. evaluation parameters of organs at risk include ­ V5%,
­V10%, ­V20%, ­V30% and D­ mean of the left lung, V
­ 5%, ­V10%
Plan evaluation and analysis and ­Dmean of the right lung, ­V5% and ­Dmean of the heart,
Dose volume histogram (DVH) was used to evaluate the and ­Dmax of the spinal cord.
exposure dose of target area and organ at risk. In the era
of IMRT technology, the ICRU83 report recommends Plan verification
the use of IMRT technology, and the evaluation of the The flux of each beam of the two technology plans was
target no longer pays too much attention to the reported collected by using the Portal Dosimetry function of the
minimum and maximum dose points, but to the ­D98% and Clinac iX linear accelerator of Varian Company of the
­D2% indicators of the recommended target. Therefore, United States. Gamma analysis, a widely used method
the specific parameters evaluated in this study include for evaluating relative dose contribution [13], was carried
high-dose flat area ­(D2%), low-dose flat area ­(D98%), aver- out using the standard of 3 mm/2%, and the passing rate
age dose ­(D50%), conformity index (CI) and homogeneity was verified by statistical dose.
Tang et al. Radiation Oncology (2023) 18:23 Page 4 of 7

Statistical analysis IMRT-SF plan exhibited better spinal cord protection

The dosimetry parameters were analyzed by IBM than IMRT-VB plan (P = 0.003).
SPSS25.0. The hypothesis test data were used to analyze Besides, IMRT-SF plan showed comparable data in
whether it conformed to the normal distribution. The heart ­V5% (P = 0.442), Heart D ­ mean (P = 0.591), ­V5%
normal distribution data were shown as mean ± SD, and of left lung (P = 0.799) and ­V5%, ­V10%, ­Dmean of right
the non-normal distribution data were shown as M (Q1, lung relative to IMRT-VB plan (P = 0.635, 1.000, 0.213,
Q3). Paired t-test was performed for normal distribution respectively).
data analysis and nonparametric paired Wilcoxon rank
sum test was used for non-normal distribution data anal- Patient‑specific QA results
ysis. P < 0.05 was considered as statistically significant. As shown in Figs. 2 and 3, the result showed that the
gamma passing rate of IMRT-SF plan was 99.16 ± 0.54%,
Results and that of IMRT-VB plan is 99.48 ± 0.46%. The passing
Target dose comparison rate of IMRT-SF plan is slightly lower than that of IMRT-
As shown in Table 1, the dosimetric indexes of CI, HI, VB plan (t = − 9.798, P < 0.0001).
­ 2%, ­D98% and D
D ­ 50% of IMRT-SF plan were significantly
better than those of IMRT-VB plan (P < 0.05). In terms Discussion
of monitor unit (MU), the average MU of the IMRT-SF Many studies have shown that the intensity modu-
plan was much higher than that of the IMRT-VB plan lated radiotherapy (IMRT) mainly in the tangent field
(866.0 ± 68.1 MU vs. 760.9 ± 50.4 MU, P < 0.05). of postoperative radiotherapy of breast cancer, can not
only improves the dose uniformity, but also reduces the
Comparison of organs at risk
As shown in Table 2, compared with IMRT-VB plan,
IMRT-SF plan had better dosimetric advantages in V ­ 10%,
­V20%, ­V30%, ­Dmean of left lung (P < 0.05). Moreover,

Table 1 Comparison of target dosimetry and MUs between two

plans (x ± s)
Parameter IMRT-SF IMRT-VB t-stat P-value

CI 0.83 ± 0.03 0.68 ± 0.04 19.618 < 0.01

HI 0.07 ± 0.004 0.16 ± 0.01 − 26.010 < 0.01
D2%/cGy 5315.7 ± 20.1 5663.9 ± 34.3 − 30.826 < 0.01
D98%/cGy 4966.2 ± 9.3 4805.5 ± 52.0 9.822 < 0.01
D50%/cGy 5163.1 ± 13.5 5394.3 ± 25.3 − 31.262 < 0.01 Fig. 2 Flux map of actual collection of EPID of two plans for the same
MU 866.0 ± 68.1 760.9 ± 50.4 6.645 < 0.01 patient, a IMRT-SF plan, b IMRT-VB plan

Table 2 Comparison of dosimetry of OARs between two plans (x ± s)/M(Q1, Q2)

Parameters IMRT-SF IMRT-VB t/z-stat P-value

Left lung ­V5/% 44.60 (43.53, 49.13) 44.75 (42.98, 48.93) − 0.255 0.799
Left lung ­V10/% 30.72 ± 3.21 31.39 ± 2.99 − 2.831 0.02
Left lung ­V20/% 19.10 ± 1.91 19.64 ± 1.78 − 5.576 < 0.001
Left lung ­V30/% 12.86 ± 1.52 13.70 ± 1.56 − 7.517 < 0.001
Left lung ­Dmean/cGy 1047.78 ± 83.38 1097.28 ± 77.94 − 8.016 < 0.001
Right lung ­Dmean/cGy 109.94 ± 38.15 108.20 ± 35.71 1.341 0.213
Heart ­V5/% 34.14 ± 4.81 33.52 ± 4.64 0.804 0.442
Heart ­Dmean 631.25 ± 80.07 635.76 ± 86.82 − 0.558 0.591
Cord ­Dmax/cGy 48.17 ± 6.08 48.78 ± 6.01 − 3.966 0.003
Right lung ­V5/% 2.30 (1.25, 3.43) 2.40 (0.93, 3.38) − 0.475 0.635
Right lung ­V10/% 0 (0.00, 0.00) 0 (0, 0.10) 0.000 1.000
Tang et al. Radiation Oncology (2023) 18:23 Page 5 of 7

Fig. 3 For the 3%/2 mm evaluation criteria, gamma passing rate

radiation dose to the lung, spinal cord and other organs technology with tangent field. The conformal index
at risk [14, 15]. In order to compensate for the target area (CI), the homogeneity index (HI), ­D2%, ­D98% and ­D50%
movement caused by organ movement and positioning were significantly better in IMRT-SF plan than those in
errors, the target area of breast cancer generally expands IMRT-VB plan (P < 0.05). The average MU of the IMRT-
CTV by 5–10 mm as PTV, which makes the PTV in the SF plan was much higher than that of the IMRT-VB plan
chest wall area expand directly outside the body. Since (866.0 ± 68.1MU vs. 760.9 ± 50.4MU, P < 0.05). In terms
the photon dosimetry possess the characteristics of dose of organ at risk protection, IMRT-SF plan had more
building area, the IMRT plan optimization process will advantages in the protection of ipsilateral lung and spinal
continuously increase the dose of the skin and the area cord than IMRT-VB plan (P < 0.05). However, default val-
outside the skin, resulting in unreasonable optimization ues of the "Skin flash" tool were adopted in the IMRT-SF
results and even failed plan. In response to the above plan, whether the adjustment of the default parameters
problems, the ICRU 62 report and other scholars have has an impact on the total monitor unit needs to be fur-
proposed some relevant solutions [5, 16, 17]. Sankar et al. ther studied. Giorgia et al. [22] assigned soft-tissue equiv-
[2] used the ‘skin flash’ tool of Varian eclipse planning alent HU to its artificial expansion. According Giorgia N’s
system for dose expansion to effectively exteriorize skin research, the virtual bolus was specified as 0 HU in our
flux to meet clinical therapeutic requirements. Consist- IMRT-VB plan as it is much closer to human muscle and
ent with previous studies reported by Chopra [18] and adipose tissue. However, Ugurlu et al. [23] specified the
Morrow [19], the flux optimization results of the IMRT- HU value of virtual bolus as − 700, while Thilmann et al.
VB and IMRT-SF plans in this study have realized the [24] specified the HU as − 60. Since there were differ-
dose intensity expansion of 0.5 cm towards the thorax, ent choice of the HU values of the virtual bolus, the most
which effectively solves the problem of insufficient dose appropriate HU value needs to be further explored and
and off-target effects in the chest wall target area caused whether the changes of the HU value would affect the
by respiratory movement. total monitor units still needs to be further studied.
Patients with breast cancer undergoing postoperative It has been reported that adding effective bolus can
radiotherapy may miss the target in the actual treatment increase the skin surface dose of photon rays with 6MV
process due to the thickness of their chest wall and res- energy from 10 to 40% to nearly 100% [25]. However,
piratory motility, leading to insufficient actual radiation for patients with no skin invasion, the skin surface dose
dose to the target area of the chest wall [20, 21]. In this level does not need to reach the 100% dose level. Once
study, for patients receiving chest wall target radiother- the bolus is added, it may aggravate acute skin injury,
apy, two different dose intensity expansion methods of interrupt the treatment, and then increase the risk of
radiotherapy plans were designed using eight field IMRT chest wall recurrence. Studies [26, 27] found that bolus
Tang et al. Radiation Oncology (2023) 18:23 Page 6 of 7

was unable to reduce the recurrence rate of chest wall Author contributions
RT and YL conceived and designed this study. Treatment planning and plan
and improve the survival rate. Lizondo [3] found that verification were conducted by RT, LZ, YW and QX. Data analysis were per-
a 1 cm bolus thickness equal to the CTV-PTV margin formed by AL, YL and GD. RT and YL mainly wrote and revised the manuscript.
plus 5 mm. Therefore, in our study, the IMRT-VB plan All authors read and approved the final manuscript.
uses a 1 cm virtual bolus to achieve the purpose of dose Funding
intensity expansion, and the virtual bolus is removed This work was supported by Natural Science Foundation of Guangdong
in the final dose volume calculation stage, which could Province (Grant No. 2022A1515012620); Science and Technology Program of
Guangzhou (Grant Nos. 202002030075 and 2023A04J00186); President’s fund
not only achieve the purpose of dose intensity expan- of Integrated hospital of traditional Chinese Medicine (Grant No. 1202103008).
sion, but also has a certain protective effect on the skin.
Even so, the dose level ­(D2%) of IMRT-VB plan in the Availability of data and materials
The data that support the findings of this study are available from the cor-
high dose hot zone of the target area is still slightly responding author upon reasonable request.
higher than that of IMRT-SF plan. The AAPM TG218
report [28] pointed out that it is too sweeping to adopt Declarations
a dose distance error standard of 3%/3 mm γ analy-
sis criteria in the clinical IMRT plan validation analy- Ethics approval and consent to participate
This study was approved by the Ethical review Board for research of TCM-
sis. Therefore, the more critical γ Analytical standard integrated Hospital of Southern Medical University. All patients have signed
(3%/2 mm) was employed in our study. Although the informed consent.
experimental results show that the γ passing rate of
Consent for publication
99.16 ± 0.54% in IMRT-SF plan is slightly lower than All authors have approved the manuscript and agree with submission to
that of 99.48 ± 0.46% in IMRT-VB plan (t = − 9.798, Radiation Oncology.
P < 0.0001), the gamma passing rate both exceeded 95%,
Competing interests
indicating that both plans met the clinical treatment The authors declare that they no competing interests for this article.
requirements. Although this study revealed the dosi-
metric effects of IMRT-SF and IMRT-VB dose expan-
Received: 30 November 2022 Accepted: 31 January 2023
sion methods on target area irradiation of chest wall
and organs at risk after breast cancer surgery, there are
still some limitations, research samples amplification
and multi-center validation were needed for further
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