Patient History

A 56 year-old male with mycosis fungoides of the neck, face, and scalp presented to the clinic (Figure 1). Due to the extensive disease and its location, a VMAT technique was selected as the treatment approach.

Figure 1. Pictured is the patient prior to treatment

Treatment Summary

The patient underwent an initial CT simulation with a wire to outline the CTV for contouring. A bolus was created using Adaptiiv’s 3D Bolus software and ordered via the Adaptiiv On Demand service. The bolus had a thickness of 1 cm and extended at least 2 cm beyond the CTV. A planning CT was acquired with the bolus in place (Figure 2). The treatment plan consisted of 3 half arcs (2 coplanar arcs and 1 non-coplanar vertex arc) and delivered a dose of 2 Gy/fx to a total of 24 Gy.

Figure 2. Patient with bolus at second CT simulation prior to treatment.

3D Bolus Creation

The patient underwent an initial CT simulation with a wire to outline the CTV for contouring. A bolus was created using Adaptiiv’s 3D Bolus software and ordered via the Adaptiiv On Demand service. The bolus had a thickness of 1 cm and extended at least 2 cm beyond the CTV. A planning CT was acquired with the bolus in place (Figure 2). The treatment plan consisted of 3 half arcs (2 coplanar arcs and 1 non-coplanar vertex arc) and delivered a dose of 2 Gy/fx to a total of 24 Gy.

TrueFlex Bolus Manufacturing

The AOD service processed the mould design and 3D printed the mould (Figure 3). The printed mould was then filled with EcoFlex 00-30 silicone to create the final TrueFlex bolus. This silicone material provides a soft touch and high flexibility, prioritizing patient comfort while conforming to the treatment area.

Figure 3. 3D Printed TrueFlex Bolus.

Quality Assurance

To ensure the quality of the TrueFlex bolus, the AOD service performed comprehensive quality assurance checks. These checks verified that the physical density and spatial accuracy of the bolus met all specified tolerances. A CT of the bolus was acquired to confirm the HU accuracy.

Dose Calculation and Verification

The custom bolus was received and the patient was scanned with the Adaptiiv bolus in place (Figure 4).

Figure 4. Bolus fit on planning CT (left) and CBCT (right).

This newly acquired CT image set was used for the final plan creation. The bolus was included in the body contour. The patient received 24 Gy over 12 fractions, with a prescribed treatment percentage of 95%.

Figure 5. Dose Volume Histograms (DVHs) for both the target and critical structures demonstrating excellent target coverage.

Results and Findings

The Adaptiiv software application provided fast design of a silicone bolus. The Adaptiiv On Demand (AOD) program successfully delivered the TrueFlex order within three business days. A verification CT confirmed the accurate shape and positioning of the bolus. The resultant silicone bolus was seen to be highly uniform on CT with a mean of 140 ± 40 HU. Daily CBCT showed consistent and accurate positioning throughout the treatment course. The patient tolerated the treatment regimen exceptionally well, and the TrueFlex bolus significantly improved the daily set up process.

Summary

• Enhanced Dose Distribution: TrueFlex bolus helped to achieve a more uniform dose distribution over irregularly shaped treatment areas, ensuring that the target tissues received the intended dose.
• Reduced Air Gaps: TrueFlex bolus closely conformed to the patient’s anatomy, ensuring a snug fit, which lead to improved treatment accuracy and effectiveness.
• Improved Patient Comfort: TrueFlex bolus facilitated consistent and reproducible placement during daily treatments overall contributing to the overall patient experience and comfort.
• Decreased Patient Set Up Time: The custom TrueFlex bolus significantly reduced set up time in the treatment unit.