You are on page 1of 13

Assessment of Surface Dose in Wet Towel Bolus with

Various Water Content

Yukie Furukawa
Kate Richmond

Indiana University School of Medicine


Health Professions Programs
Radiation Therapy
ABSTRACT

Bolus is used in radiation therapy to act as a tissue-equivalent material to increase the


surface dose to the skin. Wet towel boluses have often been used, however the saturation of the
towel with water is difficult to measure in a clinical setting. A commercial bolus (Superflab) is
commonly used because it is clinically consistent. While previous studies evaluated the effect of
unregulated water content in wet gauze bolus, this study compares the water content in wet towel
bolus of similar thickness with a commercial bolus in an attempt to compare the efficacy of each
material. Data was collected using a 10 x 10cm2 field size at 6 and 16 MV beam energy for one
dry towel bolus, three boluses with various water contents, and three boluses with unregulated
water content. Hounsfield units of the controlled water content were obtained on a CT simulator
and the surface dose was measured on a Varian linear accelerator using a Markus parallel-plate
ionization chamber in a solid water phantom. The results showed that variation in water content
in a wet towel bolus can lead to undesired percent surface dose compared to Superflab material
of the same thickness. Based on these results, it can be concluded that patients may be receiving
inconsistent surface dose during treatments when wet towel bolus is utilized if water content is
not regulated. While it is convenient to use wet towel bolus, the oncology team should be aware
of potential variation in treatment. In our experiments, as the water saturation increased the
percent surface dose approached closer to that of the commercial bolus. The unregulated wet
towels that mimicked common practice in the clinical setting did not perform as well as the
commercial bolus.

INTRODUCTION

Radiation therapy treatments often use a tissue-equivalent material, referred to as a bolus,


placed directly on the skin to increase the surface dose that can be used either in photon or
electron treatments.1 Khan (2014) has provided detailed information about surface dose and how
it is impacted by various parameters.2 For a bolus to have effective dose distribution
characteristics it must have physical properties similar to soft tissue or water. Other
considerations for selecting appropriate bolus material include it being non-toxic, flexible and
conforming, easily reproducible, cost effective, and durable. 1 Differences between bolus and
beam spoiler that increases surface dose have been described by Das et al.3 Superflab (made by
CIVCO Medical Solutions) is a commercially available product commonly used as bolus
material because it meets the desired criteria and can be cleaned and reused.2 However, it does
have some restrictions in regards to flexibility when used for irregular contours and
infectious/contaminated areas. The breast, chest wall, ear, and intergluteal cleft are examples of
irregular body contours that may require a different material to avoid an air gap between the
bolus and skin surface. Superflab may also not be ideal for tumors that are visible and exposed
through the skin surface, infectious, or bleeding. Wet towel linen and wet gauze have been used
as bolus to correct for the presence of air gaps and on infected areas. The amount of water used
to wet the towel or gauze is commonly measured subjectively by the radiation therapist. The
main issue associated with this is that the water content may vary in day-to-day set-ups which
can result in over saturation or under saturation of the bolus and decrease its effectiveness. 2

A study by Benoit et al evaluated the effect of unregulated water content in wet gauze
bolus. Their study found that subjectively measuring the water content of wet gauze bolus leads
to undesired bolus effects. They suggested if wet gauze bolus is used clinically, it should have a
physical density of 1.02g/cm3 in order to achieve the similar effect of Superflab.2 In addition,
Vyas et al compared other tissue equivalent bolus materials, including Play-Doh, uncooked
rice, and Vaseline, to name a few. Their findings mention concerns with utilizing wet gauze as
bolus. The authors state that it would be challenging to reproduce the exact bolus effects using
wet gauze since there is high level of precision required to obtain the appropriate water
saturation.4 Furthermore, a study conducted by Banaee et al showed inadequate dose
distributions of wet towel bolus due to its different densities and other physical specifications.
They suggest that neither wet towel nor wet gauze should be used as a substitute for commercial
bolus.5 One study noted the unintended bolus effect of patient coverings. Dry linen (such as
gowns, sheets, and towels often used to cover patients for warmth or comfort) has been shown to
increase the surface dose with increased thickness of covering.6 Although this was not the focus
of our study, we found similar results to be noteworthy.

The goal of this study was to evaluate the change in the bolusing effect of the wet towel
with different water volumes. Our research focused on comparing the water content in wet towel
bolus to Superflab commercial bolus to evaluate the impact of patient surface dose. We
investigated the effectiveness of various preparations of wet towel boluses compared to
commercial bolus. We hypothesized that unregulated wet towel bolus may create inconsistencies

2
in the patient surface dose. Radiation therapists should understand the need for appropriate
water saturation to create precise bolusing effects and to understand how it affects patient surface
dose.

MATERIALS AND METHODS

Measurements were obtained using different bolus materials including wet towels and a
Superflab commercial bolus gel pad. The commercial bolus dimensions were 30cm x 30cm x
0.5cm. All wet towels were fabricated from a large towel (55cm x 100cm) used in the Radiation
Oncology department at Indiana University Health. The large towel was made of 86% cotton
and 14% polyester had been laundered multiple times in the past. Four small pieces with a size
of 7.5cm x 15cm were cut from the large towel, which were folded in half, length-wise. The
towels were folded in half since that is how the effect of 0.5 cm Superflab is recreated in
clinical settings. For fabrication of the wet towel boluses, different volumes of water (0, 10, 20,
and 30 cm3) were uniformly distributed on the towel using a 60 milliliter Becton Dickinson
irrigation syringe. The wet towels were then individually wrapped in a sheet of plastic wrap to
prevent leakage or evaporation of the water. The wet towel boluses were labeled and the same
towels were used for all measurements.

In the first part of the study, a Brilliance Big Bore CT simulator (Philips Healthcare) was
used to obtain the attenuation in Hounsfield units of the wet towels and the commercial bolus
pad. The wet towels and the commercial bolus were placed on the patient couch assembly and
were then scanned in the transverse plane. The scanning parameters used were 120kV, 300mAs,
325mA, and 3mm slices. A uniform area of 154 mm2 was used to obtain the Hounsfield units of
the each bolus.

For the second part of the study, surface dose was measured using 6MV and 16MV
photon energies generated by a Clinac 2100 C linear accelerator (Varian Medical Systems). The
surface doses were measured at the central axis with and without different bolus materials using
a 10x10cm2 field size for each energy. For each measurement, 100 monitor units (MU) were
administered with a dose rate of 500MU per minute. Ionization measurements were obtained
under each bolus using a Markus parallel-plate ion chamber (model N23343, PTW-Freiburg).
The dimensions of the Markus ion chamber are 2mm electrode separation, 5.3mm diameter ion

3
collector, 2.5mg cm-2 entrance window and 30mm wall diameter. A custom slab piece (30 x 30
x 2 cm3) (RMI) with cavities was used to hold the Markus ion chamber. In addition, a solid
water phantom (30 x 30 x 6 cm3) (Solid Water RMI model) was placed below the custom slab
piece to account for backscatter. The chamber was placed at the central axis and the source to
chamber distance of 100cm was maintained for all of the measurements. To prevent water
leakage from the wet towel to the ion chamber a sheet of plastic wrap was placed across the
custom slab piece. The charge was measured with a Unidos electrometer Model 10005-50258
(PTW Freiburg). For each bolus material and energy, three independent measurements were
made and the mean was calculated. There were no corrections for barometric pressure or
temperature. Plate separation correction, as shown by various authors, was not used. This is due
to the fact that we report relative surface dose.7,8

For the third part of the study, three large towels (55cm x 100cm) were used to simulate
the bolus method commonly utilized in clinical settings. Three large towels were saturated under
a faucet and the water content of the towel was subjectively measured. The first two wet towels
were hand rung after being saturated to prevent water drip. The third wet towel was not rung
although it was clear that the towel was oversaturated with water. After the towels were wet they
were folded in half then placed on the custom slab piece to obtain measurements. The towels
were not wrapped with plastic in this part of the study to recreate practices used in the clinical
setting as much as possible. All other experiment methods and parameters stayed the same
except for the subjects being studied. For each bolus and energy, three independent
measurements were made under the same conditions as part two and the mean was calculated.

RESULTS

Table 1 shows the CT- Hounsfield Units for Superflab and the wet towel boluses with
different water contents. The water content of each bolus (where applicable) is shown in Table
1. The standard deviations indicate a lack of homogeneous material in the wet towel bolus. The
results show that the Hounsfield Unit of the wet towel bolus varies depending on the water
content. There was a consistent increase in the Hounsfield Units of the wet towel bolus as the
water content increased (Figure 1). The Hounsfield unit of the towel with no water (bolus 1) was
close to that of air (HU=-1,000) while the water-saturated towel (bolus 4) had a Hounsfield Unit
close to that of water (HU=0). As expected, Superflab had a Hounsfield Unit of -243.247.5

4
which is equivalent with soft tissue. Although the standard deviation is large, bolus 3 had the
closest attenuation characteristic to that of 0.5cm Superflab. Based on the results of the HU
data, it appears that wet towel boluses can mimic soft tissue when the appropriate amount of
water is used. In addition, the values obtained from the CT scans indicated that wet towel bolus
does not create any artifacts.

Table 2 shows the ionization charge with and without the various bolus materials,
measured via the Markus ion chamber for 10 x 10cm field. All ionization measurements were
normalized to the measurement obtained at the depth of dmax which Khan defines as the peak
absorbed dose on the central axis.2 The measured charge was normalized to the charge at a
1.5cm depth for 6MV photon energy and a 3cm depth for 16MV photon energy. Results for
percent surface dose were plotted as a function of water content (Figure 2). The results indicate
an overall increase in percent surface dose with increasing water content in the wet towel bolus.
Percent surface dose without using a bolus is much smaller than with a bolus. The graph shows a
linear increase in percent depth dose as the water content of the towel increases, indicating that
the bolus effects of the wet towel bolus is proportional to its water content. A similar pattern can
be seen for both 6MV and 16MV photon energies. For both 6MV and 16MV photon energy the
dose characteristics of the wet towel bolus with 30ml of water are similar to that of 0.5cm
Superflab. Wet towel boluses containing less than 30ml had significant differences in the
percent surface dose compared to that of Superflab.

There was an additional finding indicating that placing a towel without water can
increase the percent surface dose. Although it was not part of the research objectives, it must be
noted that placing towels, or linen, on the patients skin surface can potentially increase the
percent surface dose by up to 20%. This finding was consistent to that of a study done by
Fagerstrom and Hirata.6

Table 3 shows the measurements obtained by subjectively determining the water


saturation in a wet towel bolus, which simulates how they are constructed in the clinical setting.
Surprisingly, the difference in the percent depth dose was large between Superflab and the wet
towel bolus. As shown in Figure 3, there is more than a 15 % difference in the percent surface
dose for both 6MV and 16MV photon energies when the wet towels are rung out as compared to
Superflab (trial 1 & trial 2). When the towel is not rung out after being wet (trial 3), the percent

5
depth dose is closer to that of 0.5 cm Superflab, but a significant difference can still be
observed. The results show that a wet towel bolus, even when it is oversaturated with water,
does not have an equivalent bolus effect of Superflab. Also, since this towel was not wrapped
with plastic, water leaked from the towel which potentially affected the water saturation of the
bolus during the measurements. It must be noted that when the towel was oversaturated water
continued dripping off the treatment couch and pooled on the floor, therefore the use of
oversaturated towels may not be ideal in clinical settings unless the wet towel is contained in a
plastic sheet or a bag.

DISCUSSION

According to data results, subjectively judging the water content in towel bolus will lead
to under-dosing the surface. There was an evident change in dose in wet towel boluses compared
with Superflab commercial bolus. The water content in regulated and unregulated towels
results in an undesirable decreased surface dose to the patient. The water content in a
subjectively made bolus can be too low and therefore not provide a surface dose as high as
commercial bolus. Excessively saturated, dripping wet towels provided the closest results to the
commercial product, however these risk losing water volume throughout treatment and water
dripping off the table and onto the floor or electronics. Also, wet towels may dry out or lose
water during the course of the treatment. If a towel is draped over a patient there is also potential
for the water to leak off the patient or treatment table and damage electronics in the treatment
room.

There were several limitations that should be addressed in this study. Ignoring the
possible effects of temperature and barometric pressure, data for the wet towels were obtained on
three different days; towels were scanned on the CT simulator on a different day than measuring
the surface dose with the towel samples on the Varian linear accelerator. The full towels with
unregulated water content were measured for surface dose on a different day than the towel
samples. This was due to restrictions regarding machine and physicist availability. In the first
and second experiment for obtaining CT data and surface dose, towel samples were used (7.5 x
7.5 cm), where the third experiment used a full towel. Similarly, in the first and second
experiment, towel samples were wrapped in plastic, whereas in the third experiment the full
towels remained unwrapped. Typically, linen and gauze bolus are measured to maintain a

6
specific thickness for every treatment. The thickness of the wet towel sample was not controlled
in this experiment. The initial towel sample was approximated to be 0.5 cm, however the
thickness was subject to variance with the increase in water content. Although an increase in
water content resulted in a less thick bolus, the focus of this study was solely to evaluate the
water content. Thus, layers of linen were not added to meet a specific thickness measurement. In
addition, the original plan included assessing 40 ml of water content (bolus 5); however, the
towel sample could not contain that high volume of water. Thus, we were unable to obtain
accurate data and bolus 5 was excluded from the data samples. We conjecture that such data
would follow a linear trend and provide a higher percent surface dose than a commercial bolus.

Future studies should control as many variables as possible to see if they produce similar
results. It would be useful to evaluate smaller increments of water content, such as 5mL, when
comparing boluses. This could be performed with wet towel and wet gauze bolus using photon
and electron beams and various field sizes. Treatment planning software also may be utilized to
further evaluate dose distribution and feedback from research studies like this one on boluses can
help to educate oncologists and therapists in ways to provide better treatments. This is very
similar to the data presented by Akino et al (2014).9

CONCLUSION

This study supports the data found in previous studies that it is preferable to control water
content in wet towel boluses to produce dose results comparable to commercial bolus. This can
lead to providing more accurate, consistent, and reliable surface dose to patients. Unfortunately,
current practices involve subjectively judging the wetness of the bolus which may result in
variable surface dose on day to day basis. Results showed that subjectively judging the water
content will lead to decreased surface dose. In this experiment results showed decreased surface
dose by 16% for 6MV photons and 15% for 16MV photons. Also it was noted that Superflab
has some limitations with flexibility in irregular body contours and sometimes presents an
undesirable air gap. Therefore in clinical practice wet towels or gauze may be necessary for
specific body contours to reduce the presence of an air gap or to avoid contamination or
infection. Such examples include the breast, chest wall, intergluteal cleft, and ear auricle, among
others. It is the role of the therapist to provide consistent and reproducible treatments and be
knowledgeable about the effects associated with different treatment setups. It is important for

7
therapists to have an understanding of how bolus water content affects dose because the
consistent effectiveness of saturated linen or gauze should not be assumed. Any variances
introduced by bolus methods or preferences for materials should be communicated with the
physician. A simple method of sealing saturated wet gauze should be devised that keeps water
content uniform and same as prepared.

Based on the results in this experiment we suggest that if wet towels are frequently used
in the department, the oncology team (physicians, physicists, dosimetrists, and therapists) should
assess the specific amount of water needed to be equivalent to a commercial bolus. This consists
of measuring surface dose with various towel water volumes in order to determine the results of
over or under dosing patients. The team should select a method that produces results consistent
with a commercial or other uniform bolus material. Additionally, clear margins should be set for
variability while still maintaining a consistent dose distribution. A key factor for radiation
therapists is accurate and consistent treatment set ups and methods. This starts when radiation
therapists are aware of the pros and cons of various treatment set-ups, such as the usage of bolus
materials. A complete understanding of set-up variances along with a focus on striving for higher
and consistent treatment standards is the best strategy for treating cancer patients and can yield
the most positive results and treatment outcomes.

8
REFERENCES

1. Benoit J, Pruitt AF, Thrall DE. Effect of wetness level on the suitability of wet gauze as a
substitute for Superflab as a bolus material for use with 6MV photons. Vet Radiol
Ultrasound. 2009;50(5):555-559
2. Khan FM, Gibbons JP. The physics of radiation therapy, 5th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2014.
3. Das IJ, Kase KR, Copeland JF, Fitzgerald TJ. Electron beam modifications for the treatment
of superficial malignancies. Int J Radiat Onol Biol Phys. 1991;21:1627-1634.
4. Vyas V, Palmer L, Mudge R, et al. On bolus for megavoltage photon and electron radiation
therapy. Medical Dosimetry. 2013;38:268-273
5. Banaee N, Nadaie HA, Nosrati H, et al. Dose measurement of different bolus materials on
surface dose. J Radioprotect Res. 2013;1(1):10-13. doi:10.12966/jrr.08.02.2013.
6. Fagerstrom J, Hirata E. Surface dose effects of linen coverings for breast and chest wall
patients. Radiation Therapist. 2014;23:119-124
7. Velkley DE, Manson DJ, Purdy JA, Oliver GD. Buildup region of megavoltage photon
radiation sources. Med Phys. 1975;2:14-19
8. Gerbi BJ, Khan FM. Measurement of dose in the buildup region using fixed-separation
plane-parallel ion chambers. Med Phys. 1990;17:17-26
9. Akino Y, Das IJ, Bartlett GK, Zhang H, Thompson E, Zook JE. Evaluation of superficial
dosimetry between treatment planning system and measurement for several breast cancer
treatment techniques. Med Phys. 2013;40:011714.
Table 1. The Hounsfield Units of various bolus types on a single representative CT slice. Each measurement was
taken using an area of 154mm2
Bolus Type Hounsfield Unit Standard Deviation
Bolus 1 (0 cm3) -875.1 26.4
Bolus 2 (10 cm3) -540.6 68.4
Bolus 3 (20 cm3) -271.2 108.2
Bolus 4 (30 cm3) -101.3 111.8
0.5cm Superflab -243.2 47.5

Table 2. The ionization charge with or without bolus materials measured with the Markus ion chamber for 6MV
and 16MV photon energies. Each measurement was normalized to the maximum ionization charge for both
energies to calculate the percent surface dose.
Bolus Type Electrical Charge (nC) % Surface Dose Electrical Charge (nC) % Surface Dose
6MV 16MV
No Bolus 0.561 25 0.332 17
Bolus 1 (0 cm3) 1.000 45 0.564 29
Bolus 2 (10 cm3) 1.511 68 0.916 46
Bolus 3 (20 cm3) 1.729 78 1.105 56
Bolus 4 (30 cm3) 1.938 88 1.324 67
0.5cm Superflab 1.919 87 1.271 64
No Bolus (1.5cm depth) 2.210 100 N/A N/A
No Bolus (3.0cm depth) N/A N/A 1.975 100

Table 3. The ionization charge with bolus materials measured with the Markus ion chamber for 6MV and 16MV
photon energies. Water content was measured subjectively for all the wet towel bolus. Each measurement was
normalized to the maximum ionization charge for both energies to calculate the percent surface dose.
Bolus Type Electrical Charge (nC) % Surface Dose Electrical Charge (nC) % Surface Dose
6MV 16MV
Trial 1 (rung out) 1.577 71 0.967 49
Trial 2 (rung out) 1.558 70 0.957 48
Trial 3 (oversaturated) 1.737 79 1.065 54
0.5cm Superflab 1.919 87 1.271 64
Figure 1. The Hounsfield Units of various bolus types on a single representative CT slice. Each measurement was
taken using an area of 154 mm2

Bolus 1 Bolus 2 Bolus 3 Bolus 4 0.5cm


(0 cm) (10cm) (20 cm) (30 cm) Superflab
100.0
(Water) 0.0
-100.0
-200.0
-300.0
-400.0
-500.0
-600.0
-700.0
-800.0
-900.0
(Air) -1000.0

Figure 2. Percent surface dose plotted as a function of water content for 6MV and 16MV photon energy.

100% No Bolus
90%
80% Bolus 1
% Surface Dose

(0 cm)
70%
Bolus 2
60%
(10 cm)
50%
Bolus 3
40% (20 cm)
30% Bolus 4
20% (30 cm)
10% 0.5cm
Superflab
0%

6MV 16MV
Figure 3. Percent surface dose for 6MV and 16MV photon energy.

100%
90% Trial #1
80% (Rang Out)
% Surface Dose

70%
Trial #2
60%
(Rang out)
50%
40%
Trial #3
30% (Oversaturated)
20%
10% 0.5cm
0% Superflab

6MV 16MV

You might also like